
Class JE&ASL 

Book 3^5. 



THE PRACTICE 






MEDICINE AND SURGERY 



APPLIED TO THE 



DISEASES AND ACCIDENTS 



INCIDENT TO WOMEN. 



WE H. BYFOKD, A.M., M.D., 

AUTHOR OF "A TREATISE ON THE CHRONIC INFLAMMATION AND DISPLACEMENTS OF THE 

UNIMPREGNATED UTERUS," AND PROFESSOR OF OBSTETRICS AND DISEASES OF 

WOMEN AND CHILDREN IN THE CHICAGO MEDICAL COLLEGE. 



Second Edition, Enlarged. 



r * 



PHILADELPHIA: 
LINDSAY & BLAKISTOX. 

1867. 
v 



Entered according to Act of Congress, in the year 1867, 

By LINDSAY & BLAKISTON, 

In the Clerk's Office of the District Court of the United States for the 
Eastern District of Pennsylvania. 



PHILADELPHIA: 

CAXTON PEESS OF SHERMAN & CO. 



PREFACE TO SECOND EDITION. 



The call for a new issue of this work, affords the author an 
opportunity of expressing his grateful acknowledgments to the 
medical press, and profession generally, for the kindness with 
which they welcomed his first edition. This kindness has stimu- 
lated him to renewed efforts, and he ventures to hope that this 
second edition will be more worthy of the patronage of his pro- 
fessional friends, than the first. By comparison, the reader will 
find a large addition of new matter, and a careful improvement in 
some of the former contents of the work. Notwithstanding this 
addition, the size of the volume is not materially increased. 

Chicago, October, 1867. 



PEEFACE TO FIRST EDITION 



In presenting the following work on the Medical and Surgical 
Treatment of the Diseases and Accidents Incident to Women, it 
has been the object of the author to furnish the student and junior 
members of the profession a concise, yet sufficiently complete, 
practical, and reliable treatise, to meet their wants in every-day 
practice. Whether this object has been accomplished will be 
determined by its success alone, and for the verdict thus indicated 
the author respectfully and hopefully dedicates it to his young 
friends. 

It affords the author pleasure to acknowledge the valuable aid 
afforded by Dr. Quackenboss, of this city, in preparing this work 
for the press. 

Chicago, September, 1865. 



CONTENTS. 



PAGE 

CHAPTEK I. 

Diseases and Accidents of the Labia and Perineum, . . 17 

CHAPTEE II. 

Diseases of the Vulya, .32 

CHAPTEK III. 
Stone in the Bladder, 42 

CHAPTEK IV. 
Vaginitis, 46 

CHAPTER V. 

Menstruation and its Disorders, 67 

CHAPTER VI. 

Menorrhagia, 86 

CHAPTER VII. 
Dysmenorrhea, 99 

CHAPTER VIII. 

METATITHMENIA (MeraTidfini fiijv) ; OR MISPLACED MENSTRUATION, . 115 

CHAPTER IX. 

Acute Inflammation of the Unimpregnated Uterus, . . .126 

CHAPTER X. 

Chronic Inflammation of the Uterus and Ceryix— General 

Symptoms, 131 

CHAPTER XI. 

Chronic Inflammation of the Uterus and Ceryix — Local Symp- 
toms, 151 

CHAPTER XII. 

Chronic Inflammation of the Uterus and Ceryix — Etiology, . 166 

CHAPTER XIII. 

Chronic Inflammation of the Uterus and Ceryix — Prognosis, . 172 

CHAPTER XIV. 

Complications of Inflammation of Ceryix, . . . . 182 

CHAPTER XV. 

Position of Inflammation, 192 



Vlll CONTENTS. 



PAGE 

CHAPTER XVI. 

Progress and Terminations, 197 

CHAPTER XVII. 
Diagnosis, 202 

CHAPTER XVIII. 
General Treatment, 219 

CHAPTER XIX. 
Local Treatment, 244 

CHAPTER XX. 

Nitrate of Silver and its Substitutes, 256 

CHAPTER XXI. 

Treatment of Submucous Inflammation, 277 

CHAPTER XXII. 
Hypertrophy of the Cervix, 285 

CHAPTER XXIII. 
Perimetritis, ... . 288 

CHAPTER XXIV. 
Displacements of the Uterus, 303 

CHAPTER XXV. 

Diseased Deviations of Involution of the Uterus, . . . 344 

CHAPTER XXVI. 

Cancer of the Uterus, . 354 

CHAPTER XXVII. % 

Tumors of the Uterus, . . . . 367 

CHAPTER XXVIII. 
Ovarian Tumors, v 401 

CHAPTER XXIX. 
Diseases of the Mammae, 475 

CHAPTER XXX. 
Puerperal Convulsions, 521 

CHAPTER XXXI. 

Phlegmasia Alba Dolens, or Crural Phlebitis, .... 543 

CHAPTER XXXII. 
Puerperal Fever, . . 554 

CHAPTER XXXIII. 
Stomatitis Materna— Nursing Sore Mouth, 599 



DISEASES AND ACCIDENTS 



INCIDENT TO WOMEN 



CHAPTER I. 

DISEASES AND ACCIDENTS OF THE LABIA AND PEEINEUM 

Adhesion of the labia, and consequent occlusion of the vagina, 
sometimes occurs in infancy, or early childhood, as well as in adult 
life. The adhesions of infancy are so feeble and easily broken up, 
that they may be considered a trifling affair. Upon examining the 
parts, it will be found that there is no development of adhesive 
tissue, but the mucous membrane of the two sides is merely in 
strong coaptation. It probably is caused by the adhesive influ- 
ence of dried mucus accumulating and drying between the parts, 
when in close contact, from want of cleanliness. The vaginal 
orifice is closed up to the urethra above, and down to the four- 
chette below. The treatment consists in separating the labia, by 
forcibly pressing each in opposite directions, until the adhesion 
gives way, washing and oiling them once every day, and after- 
wards to keep them from adhering again. Should Ave not be able 
to separate them in this way, the point of a silver catheter may 
be passed down so as to interrupt it. There will be no need of 
any other instruments in the case. 

On one or two occasions I have seen firm tissual cohesions of the 
labia in childhood as the effect of ulcerative vulvar inflammation. 
In this form of adhesions it may be so firm as to require the use 
of the knife. They are, however, always superficial, and we may 
generally introduce behind the adhesions from above a bent probe 
or director. When this is the case, it is, I believe, the best plan 

2 



18 DISEASES AND ACCIDENTS OF THE LABIA. 

to separate them, by driving the bent director through the adhe- 
rent part. The same care as in the infant will prevent them from 
adhering again. 

The most grave sort of adhesions with which we meet is in the 
adult, as the effect of neglected inflammation of the vulva after 
childbirth. These adhesions are sufficient to entirely close the 
vaginal orifice by the coaptation and firm accretion of the entire 
inner surfaces of the labia. I have met with more than one in- 
stance in which the hairy margins of the labia were so nicely 
adjusted to each other, that you could not distinguish the point 
of original separation, from the perineum to the urethral orifice, 
and the finest probe would not enter the vagina anywhere. The 
depth of the adhesion may be very great, involving much of the 
vaginal cavity. 

These cases are very embarrassing, and are seldom perfectly 
remedied. It is decidedly the best plan not to interfere with them, 
until the menstrual accumulation fills up all the vaginal cavity re- 
maining open, and then our object should be to reach the accumula- 
tion with a small trocar as near the middle of the adherent parts 
as possible. Placing our patient in the lithotomy position, the 
catheter should be introduced into the urethra, the urine all drawn 
off, and the urethra held as near the symphysis pubis, or as far 
from the middle line of the vagina, as practicable. The catheter 
should be thus held by an assistant, while the forefinger of the 
left hand should be placed in the rectum. With this preparation, 
we may safely introduce the trocar into the collection of fluid as 
felt by the finger. The fluid being drawn off, the outer extremity 
of the perforation may be increased by the knife as far as may be 
desired, and as deeply as the surgeon may consider it safe. The 
opening may be increased as much as necessary by wax bougies, 
introduced and allowed to remain for twelve hours. The whole 
should be thoroughly cleansed by a syringe, with soap and water, 
as often as every twelve hours. The size of the bougies should be 
increased as often as once in twenty-four hours. If the opening 
is superficial, the treatment will not be protracted ; but if it is 
deep, it will be tedious. It should be continued until all danger 
of closure is past, and it will be best to keep the patient under 
our supervision for some time after this appears to be the case. 

Wounds. — The labia are sometimes wounded by accidents of 



DISEASES AND ACCIDENTS OF THE LABIA. 19 

some kind extraneous to the patient, and they are sometimes 
torn during labor. When the wound is deep enough to reach the 
bulb of the clitoris, alarming and sometimes fatal hemorrhage is the 
result. Professor Meigs gives an instance of great hemorrhage 
from these parts in a woman who had fallen upon a chair so as to 
cut through one of the labia. A case of fatal hemorrhage was 
caused in this city about four years since, in the following manner, 
as well as it could be learned from a legal investigation. A 
drunken husband returned home late at night, and, as was his wont 
under such circumstances, beat and kicked his wife, who was, prob- 
ably, also inebriated. He kicked her with great violence in the 
genitals, and the square-toed heavy boot, in penetrating the pelvis, 
had cut off one labium and deeply wounded the other. In six or 
eight hours after the occurrence, the woman was found dead, with 
such copious effusion of blood from the wounds as, in the opinion 
of the examining jury, to account for the fatal result. I saw a 
case many years ago, where the patient was wounded by a knife 
in one labium so as to cause very profuse hemorrhage. 

The hemorrhage being the important effect of these wounds, our 
efforts should be directed to its suppression, and this may, in most 
cases, be easily done. The bleeding part should be pressed by 
the hand firmly against the pubic ramus of the side upon which 
it is situated until temporarily arrested, when an elastic air-bag, 
or plug o? oiled cotton or lint, may be introduced to fill up the 
vagina, and a hard compress placed and held firmly by bandages, 
so as to press the wounded part between the two. When wounds 
of the labia are large and gaping, the hair should be removed, 
and the wound treated according to ordinary rules for external 
wounds. The rents occurring in labor do not, in the great majority 
of cases, require any special treatment, cleanliness and quiet be- 
ing all that is required. 

Sanguineous Infiltration. — During labor, when the parts are 
stretched to their utmost extent, some of the arterial twigs give 
way and extravasate the blood in the loose structure of one 
labium. The infiltration usually shows itself after the child has 
been delivered, but sometimes, before the head has passed, the 
swelling becomes very great, and proves an obstacle to the ex- 
pulsion of the head. When this last is the case, the blood is 
effused from a large branch of the pudic artery, and the forcible 



20 DISEASES AND ACCIDENTS OF THE LABIA. 

injection into the tissues is so great as to urge the blood so far 
in every direction as to fill a large part of the space between the 
vagina and the pelvic walls. This is a very serious state of af- 
fairs, and calls for prompt and judicious interference. I once saw, 
in consultation, a case of this kind, so extensive as to arrest labor 
for several hours. These effusions, however, do not always call 
for surgical treatment, but when, as in the case here alluded to, 
the effusion is extensive, we must make a free incision in the 
inner surface of the labium, and allow the blood to escape ; if it 
is coagulated, we should introduce the fingers and dislodge it. 
When the blood is thus evacuated, if hemorrhage continue, the 
bleeding artery must be compressed by the fingers until it ceases. 
The artery may be felt by the finger, where it crosses the plane 
of the ischium, just above its tuberosity, and as it runs along 
the ramus of the ischium and pubis. As it occurs after the ex- 
pulsion of the foetus, the branch of the artery is smaller, and, as 
a general thing, the effusion not very extensive. Water-dressing, 
some evaporating lotion, or cooling discutient, will be sufficient, 
and absorption will be effected in from one to four weeks. Sup- 
puration occasionally, I think not frequently, is excited by a 
small amount of effusion. This should be treated as an abscess. 
If the amount of blood is great, and the parts are tensely dis- 
tended even after the child is expelled, it is better to liberate it by 
incision, for fear of sloughing or extensive suppuration and serious 
damage. 

(Edema. — The distensible nature of the structure of the labia 
renders them liable to great oedematous infiltration in cases of 
general dropsy. Ordinarily, such distension is a matter of trifling 
importance, but the supervention of labor at a time when they are 
very largely swollen, is often a very embarrassing condition. They 
are sometimes so swollen as to occlude the vaginal entrance, and 
to yield only after protracted efforts, and even then, sometimes 
only after one of them has been more or less torn. When this 
excessive oedema is discovered before the head is pressing upon the 
external parts, or even when this is the case, no time should be 
lost before taking measures to lessen their size. This may be best 
done by everting first one and then the other, and making from 
ten to twenty small punctures through the mucous membrane only. 
A very sharp-pointed knife, taken between the thumb and finger 



DISEASES AND ACCIDENTS OF THE LABIA. 21 

of the right hand, so as to show only about the eighth of an inch, 
is the best instrument. Several quick, smart strokes with the in- 
strument thus held suffice for the operation. The serum begins to 
exude from these punctures, and in half an hour the swelling is 
very much reduced. 

Phlegmon. — Abscesses in the labia are apt to occur in three dif- 
ferent forms. The first is common phlegmonous inflammation, oc- 
curring in the central part of one labium, very rarely in both. 
The heat, swelling, and pain, are very great, and the inflammation 
runs its course quite rapidly, generally suppurating and discharg- 
ing in from six to eight days. This form of inflammation results 
from bruises, acrid discharges from the vagina, or the extension of 
inflammation from this cavity. It is located about the centre of 
the labium, and the swelling and tenderness are great from the 
beginning. The second form originates in over-distension of 
Duverney's gland, from a stoppage of its excretory duct. It is 
situated deeply at the lower or posterior end of the labium, and 
generally more slow in its progress. If the patient is intelligent, 
and has observed the case with care, she will tell us that there was 
a little tumor in the seat of disease for several days, and some- 
times weeks, but slightly tender at first, gradually becoming more 
so until the inflammation becomes acute, when the abscess is fully 
formed. In this stage the labium is enlarged, tender, and hot, but 
there is not the acuteness of inflammation as is seen in the first 
variety. If the surgeon has an opportunity to examine the parts 
during the progress, he will perceive a well-defined tumor, pyri- 
form in shape, with the small extremity directed to the vulva, 
while the larger passes beneath the ramus of the ischium. It will 
not seem to be, as it is not, in the central part of the labium, but 
beneath its under surface. It will bear handling somewhat freely, 
and by pressing against the ramus, and directing the pressure to- 
ward the vulvar end of it, the contents may sometimes be pressed 
out. The contents in the early stages are, for the most part r 
mucus. If examined later, the surrounding parts, the labium par- 
ticularly, will be found in a state of phlegmonous inflammation, 
which, in ten days or two weeks, suppurates, and the pus is evacu- 
ated spontaneously. In this form of inflammation, if the duct of 
the gland can be opened before the inflammation becomes consider- 
able, suppuration may be avoided. This may be done by pressing 



22 DISEASES AND ACCIDENTS OF THE LABIA. 

the fluid out, or introducing a very small probe into the canal of 
the gland, thus opening it. If these are both impracticable, it is 
better to puncture it and squeeze the contents through the outlet 
thus made. If inflammation has begun, we may treat it like the 
former variety, with leeches, purgatives, evaporating lotions, &c, 
in the earlier period, and afterwards, by poultices and anodynes, 
until the suppuration is complete, when it should be evacuated by 
puncturing it on the mucous surface of the labium. The third 
variety is characterized by a succession of small furunculi. They 
first show themselves as small points of induration immediately 
below the mucous membrane or skin, which are very tender, and 
in the course of a few days suppurate. One scarcely passes 
through these stages before it is succeeded by another, and so on 
a continuation of them march along for weeks, and even months, 
before they cease to return. This condition has existed only in 
such of my patients as were the subjects of some form of uterine 
disease, attended with leucorrhoea. They are generally anaemic, 
have slow condition of the bowels, and poor digestion. The radi- 
cal treatment consists in curing the disease of the uterus, correct- 
ing the state of the bowels by mercurial and saline cathartics, and 
reinvigorating the patient by the judicious employment of tonics. 
We may palliate the sufferings of the patient by cleanliness ; 
as bathing the parts thoroughly several times a day with pure 
cold water, and using cold water injections per vaginam, and 
making such application to every hardened point as soon as it 
shows itself as will arrest its progress. I have used successfully 
the strong tincture of iodine applied to the part, and the solid 
nitrate of silver. If either of these applications is used as soon as 
the inflammation begins to come, sometimes it will be arrested, and 
the patient escape for several days, or until another begins to 
form. Should we be unable to thus cut short the inflammation, 
we must use poultices of bread mixed with a solution of acet. 
plumbi, and anodynes, until suppuration is perfect. These small 
points of suppuration usually break themselves, and they will sel- 
dom be lanced. Notwithstanding the fact that inflammation of 
the labia is very painful, the patient will bear her distress until 
suppuration is complete, or, at least, unavoidable, in almost all 
cases, so that our treatment is confined generally to that appro- 
priate to the suppurative stage. The whole processes of inflam- 



DISEASES AND ACCIDENTS OF THE PERINEUM. 23 

mation are rapid, so that this may be an additional reason why the 
first stage is not the subject of observation. 

'' Rupture of the Labia and Perineum. — The perineum and labia 
majora are liable to be torn during severe labor. A number of 
causes may, under certain circumstances, lead to these accidents. 
A straight sacrum, by allowing the head to emerge from the pelvis 
farther back than usual, although not a frequent, is an occasional 
cause. Rigidity of the perineum, or undilatable state of the ex- 
ternal organs, a condition frequently found in aged primipara and 
occasionally in other patients, is also a cause. A large and un- 
usually ossified head, malposition of the head when the occiput 
emerges too much posteriorly, and a too narrow arch to the pubis, 
may also act as causes of rupture. 

The perineum may be, and doubtless is, not unfrequently rup- 
tured by the unskilful use of the forceps : 1st, by not making the 
proper spiral change in the position of the head, so as to bring the 
occiput under the arch of the symphysis ; or, 2dly, not causing 
this part to keep close to the symphysis, by raising the handles at 
the proper time, and to a sufficient extent ; or, 3dly, the forceps 
may be allowed to slip off the head under powerful traction. 
Mere slipping of the forceps when the points of the blades pass 
behind the head, and become detached entirely, and the convexity 
of them is not increased, will not generally produce this effect. 
When this is the manner of missing the hold of the instrument, 
the blades will be pressed close together, and pass through the 
parts without great distension. But if, instead of this mode, the 
blades spring so that the points are made to pass out over the 
largest part of the head, and thus widely separate the blades, the 
convexity becomes so great as to distend the parts enormously, 
and thus split through the fourchette first, and then the perineum, 
and finally, in some instances, the sphincters ; 4thly, by elevating 
the handles of the forceps too much, the points of the blade may 
be brought in forcible contact with the perineum, and thus, added 
to the great distension, cause rupture. 

The breach of substance, of course, differs very considerably. 
Mr. Brown divides the accident into slight and grave. He re- 
gards those as slight which are not ruptured through the sphincter, 
and considers them of but little practical importance ; and believes 
that when the sphincter is violated, and then only, need much im- 



24 DISEASES AND ACCIDENTS OF THE PERINEUM. 

portance be attached to it. The external sphincter is sometimes 
injured considerably, and the rupture stops short of its complete 
division, and at others both are torn through, and half an inch of 
the recto-vaginal septum also divided. I saw one instance in 
which the two sphincters were torn through, while the larger part 
of the substance of the perineum in front of them was uninjured; 
the child having passed through the septum into the lower rectum, 
and through the anus, producing the above rupture. This case 
did well without any operation. The wound generally commences 
at the fourchette, and extends backward towards the anus, but 
occasionally it takes a direction to one side and passes outside the 
sphincter, leaving the anal opening untouched. At other times, 
the rupture commencing at the fourchette, the rent is directed 
laterally outward, so as to separate to a greater or less extent one 
or both of the labia from the perineum. 

Effects. — I think Mr. Brown underrates the importance of some 
of the slighter forms of this accident ; for, reason as we may as 
to the means adapted to the support and maintenance of the k 
uterus in its proper position, as the floor of the pelvis, the peri- 
neum serves an important part in sustaining that organ. When 
the perineal support is lost, the positions of all the pelvic viscera 
are likely to be disturbed in their relations one to the other. It 
is very rare to see, indeed I never have seen, the uterus, bladder, 
or rectum, protrude from the vaginal orifice when the perineum re- 
tained its perfect integrity. On the contrary, one or all of them, 
when other causes co-operate, may be comparatively easily dis- 
placed, after the main portion of the perineal substance is lost. 
It will only be necessary to remember that the perineum being in 
the virgin triangular, the base at the skin, and the apex looking up 
into the cavity of the pelvis, and that the upper part, or apex, ex- 
tends up at least an inch, and reaches obliquely forward above the 
tuberosities of the ischium, and that farther behind is quite a de- 
pression, into which the uterus, bladder, and rectum, in a state of 
distension, are lodged, gravitating there in a direction with the 
superior strait, to understand the great inconvenience of its loss. 
When the perineum anterior to the sphincter is split, this muscle 
will draw the anus farther back, and thus destroy this pelvic pouch, 
leaving its contents to settle still lower down. I think that it is in 
this wise the most distressing protrusion of the vagina, bladder, 



DISEASES AND ACCIDENTS OF THE PERINEUM. 25 

rectum, and uterus, one or all of them, is permitted, if not caused. 
As an evidence that Mr. Brown does not differ from me so much 
as he seems, he has devised an operation to restore and even ex- 
tend the perineum forward, for the cure of these displacements ; 
and, as is usual with his surgery, it is a success. I do not wish 
to be understood as intending to say that in all cases of loss of 
the perineum, protrusion of these organs will necessarily occur, 
but that when extensive displacement of this kind is observed, 
it is almost always in connection with deficient perineal support. 
More serious and invariable are the consequences of the most 
extensive ruptures, — the loss of the functions of the perineum 
and sphincter both. Prolapse of the viscera and involuntary 
discharge of the contents of the rectum result. If the faeces are 
hard, the patient can generally manage to seek a proper place to 
perform defecation ; but if fluid, there is no warning until they 
flow upon the person. The mucous membrane of the vagina is 
generally irritated and inflamed, while the skin is chapped and 
excoriated from frequent contact with the faeces. 

Treatment. — Prevention, always the best treatment when avail- 
able, will vary with the cause of the rupture. When, in labor, 
the perineum is very rigid, and relaxes with difficulty, the patient 
should be placed under the influence of chloroform, which induces 
relaxation with more certainty, perhaps than any other remedy. 
Minute nauseating doses of ant. et pot. tart., every half hour, is 
next in efficiency to chloroform. I would not consent to bleeding 
in such cases, unless there was evident approach to inflammation 
in the part, and in no case is tobacco to be thought of. In this 
condition of the perineum, the irritability of the structures ought 
not to be increased by attempts to support it. The perineum 
may be supported when greatly distended, and its integrity is 
threatened by too great inclination of the presenting part back- 
ward. The object of the support, in cases where it is deemed 
advisable, should be to keep the head as close to the pubic arch 
as possible, but not to retard its expulsion. Not much force is 
allowable for this purpose, or any other in relation to the peri- 
neum. It is needless, after what has been said as to the manner 
in which this accident occurs from the use of the forceps, to in- 
dulge in special admonitions as to their use. When a patient is 
the subject of this distressing circumstance and its consequences, 



26 DISEASES AND ACCIDENTS OF THE PERINEUM. 

she may derive some palliation from the perineal pad, — to prevent 
protrusion, — cleanliness, and astringent washes and ointments. 
The curative measures depend upon the extent of the rupture, and 
the consequences of it. If the perineum, with the sphincters, is 
separated in the central line, an operation to restore the integrity 
of the parts will be indispensable to a cure. If the sphincters are 
not torn through, and there is no prolapse, the inconvenience will 
be so slight as not to demand such aid. In cases where the sphinc- 
ters are no^ ruptured, much may be done immediately after the 
accident to close or fill up the chasm without a surgical operation. 
The student may be reminded that a very easy way of ascertain- 
ing whether the rent extends through the sphincters, without in- 
spection of the part, is to learn whether the patient can control 
the escape of gas from the rectum. If she can, that muscle is not 
materially damaged. A good way to arrive at the same object, is 
to introduce the finger into the anus. The resistance to the intro- 
duction is a measure of the quantity of muscular fibre left. For 
the first four or five days after confinement, the patient must be 
confined to her side, and it would be better, also, to surround the 
limbs at the knees with a roller, or bandage, to keep them con- 
stantly in contact. By lying on the side with the limbs close to- 
gether, the parts are kept in almost perfect contact, and the 
lochial discharges flow out anterior to the wound. These two cir- 
cumstances are essential to a cure. A diligent observance of the 
position on the side for a number of days, and a close proximity 
of the knees, is apt to result in adhesion of a part of the wound 
by the first intention, and much more of it by granulation. After 
the lapse of eight or ten days, the parts ought to be inspected, and 
a healthy state of granulations encouraged by cleanliness, good 
diet, and, if need be, by a stimulating application of nitrate of silver 
every four or five days. It will not be best to use suture or other 
surgical measures in recent cases of this kind. After the oppor- 
tunity for treating such cases in their recent condition is past, 
and prolapse of the bladder, rectum, uterus, or vagina, renders 
interference necessary, the operative procedure is so similar to 
that necessary for the worst cases, that I will consider them in 
this respect together, and point out the difference as I proceed. 
For the most destructive form of rupture, the operation taught by 
Mr. I. Baker Brown is so perfect, and has been so entirely sue- 



DISEASES AND ACCIDENTS OF THE PERINEUM. 27 

cessful in my own hands, that I will not apologize for recommend- 
ing and describing it without variation. A patient, to undergo 
this operation and be cured by it, must be in good general health. 
If she is not so, the operation ought to be delayed until proper 
means can be used to effect it. A firm, plastic state of the solids, 
without unusual tendency to suppuration, will be the most favora- 
ble condition; and I have observed that patients coming from the 
country will do better to have the operation performed at once, 
and that it is better, if practicable, to send our town patients 
into the country for a month or more. Thirty-six hours before 
the operation is to be performed, we must administer an effi- 
cient but not drastic laxative ; castor oil or rhubarb will do very 
well. The patient should be placed in the lithotomy position 
before a strong light. If an anaesthetic is administered, — an'd it 
will very much facilitate the management of the patient, — it may 
be given at this stage of the proceeding. One assistant is placed 
at each side of the patient to steady the knees and hold the legs, 
while another assists in the use of instruments. The instruments 
necessary are a scalpel, a blunt-pointed bistoury, a pair of scissors, 
three large curved needles armed with double hemp cord ligatures, 
eighteen inches long, — quite strong, common hemp twine, — three 
or four small curved needles with silver wire in them, and two 
pieces of flexible catheter, three inches long, for quills. Sponges, 
warm and cold water, of course, must be at hand. The surgeon 
seats himself in front of the patient within easy reach. He com- 
mences by removing the hair from all the parts on which he is to 
operate. After which the edges of the cleft part are to be thor- 
oughly denuded. The cicatricial tissue should be all removed, 
smoothly and evenly on both sides and up to the septum, the 
lower end of which should be trimmed in the same way. No part 
of the mucous membrane or superficial tissue of any kind should 
be left, as it will inevitably prevent union. An incision on each 
side of the central line posteriorly, so as to divide most of the 
fibres of the superficial sphincter, must be made by introducing the 
blunt-pointed bistoury, about one inch and a quarter into the rec- 
tum, and then carrying the handle of the knife obliquely outward, 
so as to make the incision extend outward, from the verge of the 
anus between the coccyx and tuberosity of the ischium, about one 
inch. This will pretty thoroughly divide the external sphincter. 



28 DISEASES AND ACCIDENTS OF THE PERINEUM. 

After the bleeding ceases the rent is now ready to be closed. One 
of the large needles is made to enter the side of the wound, to the 
right of the operator, and at the upper angle, about an inch and a 
half from the edge of the cut surface, and dip down deep enough 
to go to the bottom of the torn portion, inserted into the corre- 
sponding part upon the opposing side, and come out as far removed 
from the edge to the left hand of the operator. Another ligature 
should be introduced at the central part of the cut, in the same 
manner as the first, but it will be necessary to penetrate to the 
depth of the septum, and it would be very proper to include it. 
It must be deep. A third, at the posterior part of the wound, will 
suffice to adjust the parts well. In introducing the ligatures we 
must be careful to place them so as to make the approximation of 
the surface equable and true. The quill placed on either side, the 
ligatures drawn and tied over them tight enough to bring the lips 
of the wound firmly and perfectly together, and from four to six 
silver sutures passed through the edges of the integuments and 
secured, and the operation is finished. It is advisable, I think, 
before, or immediately after the operation, to give the patient 
about two grains of opium, or its equivalent in some of its prepa- 
rations, and continue it at intervals, to keep the bowels from 
moving, and allay irritability and pain. The patient is to be 
placed on her side, and have the limbs secured by a bandage at 
the knees. The position may be carefully changed from one side 
to the other, being always particular to keep the legs close to- 
gether, and not to allow them to be used so as to contract the mus- 
cles at the pelvis. Every six hours, or oftener, the catheter is to 
be used to draw off the urine, lest it runs into the wound and 
vitiates the inflammation. The wound should be kept covered 
with pledgets of lint saturated with simple cerate or cold water. 
The deep ligatures commence ulcerating on the third day, and 
sometimes sooner, and if this does not progress too rapidly, they 
may be left in place four days, but if the ulceration is active, they 
may be removed on the third. It will only be necessary to cut 
the ends of the ligatures over one quill, when they may be re- 
moved by drawing upon the other. Soon as the suppuration begins 
we cannot be too careful about cleanliness. Plenty of clean tepid or 
cold water must be injected into the vagina and rectum two or three 
times a day, while the external parts are sponged and cleansed as 



DISEASES AND ACCIDENTS OF THE PERINEUM. 



29 



often. The young operator need not be discouraged if, upon ex- 
amination, the wound is not all closed by adhesive inflammation. 
My experience is that this immediate and perfect closure does not 
usually take place, but that much of the deep-seated portion is left 



Fie. l. 




Shows the parts brought together by the deep and interrupted sutures. 

to be filled by granulations, and it is sometimes several weeks be- 
fore this is accomplished. The skin and integuments generally 
unite by the first intention, and when this is the case, there is not 
much danger of failure, provided we keep up a granulating surface 
all over the unhealed portion of the wound, and observe perfect 
cleanliness. The superficial silver sutures may remain for ten or 
twelve days, as they produce no irritation whatever. At the end 
of twelve days some laxative will be necessary if the bowels have 
not been moved. The diet and medicine of the patient while in 
bed, after the operation, cannot be uniform in all cases, and are 
to be governed wholly by the state of the system ; it will be bet- 
ter, I think, to err in favor of good supporting diet, stimulants and 
tonics, rather than risk impairing the general health by abstemi- 



30 DISEASES AND ACCIDENTS OF THE PERINEUM. 

ousness. Adhesive inflammation is promoted by a high state of 
physical health, and suppuration by a low condition of it, and aside 
from imperfection of the operator's proceedings, we have most to 
fear from early, copious, and persistent suppuration. 

When the rupture is recent, the parts may be restored by merely 
using the sutures, and the incisions through the sphincters, in the 
case of complete rupture, or without these when the muscles are 
not torn. 

The operation is performed quite differently by Dr. Emmet, 
the skilful and ingenious surgeon of the Woman's Hospital, New 
York. I subjoin a description as I find it in the New York 
Journal of Medicine for December, 1865, from the pen of Dr. 
Emmet : 

" As early as 1855 Dr. Sims, in the Woman's Hospital, simpli- 
fied this operation by bringing the scarified edges of the laceration 
together by means of deep interrupted silver sutures, and from 
this time the use of the quill suture, or a division of the sphincter 
ani, has been abandoned. Further experience demonstrated a ne- 
cessity for the use of a short rectal tube for some ten or twelve 
days after the operation, that a free escape of flatus might be un- 
obstructed. Where the laceration of the perineum has extended 
only to the sphincter, the rectal tube is not needed, and three in- 
terrupted sutures are generally sufficient ; if more extensive, so as 
to involve the muscle, two in addition are required. The first su- 
ture passed should be the one nearest to the rectal mucous mem- 
brane, and should be made to follow the laceration entirely around, 
so as to bring together the sphincter. The second should also in- 
clude the sphincter, and be passed in the recto-vaginal septum, 
just beyond the first one. The remaining sutures are introduced 
(as in the operation for a partial laceration of the perineum) 
through one labia about half an inch from the edge on one side, 
introduced from within outward into the other, and withdrawn at 
a point equally distant, so as to approximate perfectly opposite 
surfaces. If the laceration has extended up the recto-vaginal 
septum for some distance beyond the sphincter ani, the edges 
should be brought together down to the sphincter by interrupted 
silver sutures, at a distance of about five sutures to the inch. On 
introducing the first suture to clear the perineum, care must be 
taken that it is passed between the first and second sutures unit- 



DISEASES AND ACCIDENTS OF THE PERINEUM. 31 

ing the septum, and the next one in turn between the second and 
third. Without this precaution an opening into the vagina will 
be produced just behind the sphincter, from the fact that, as one 
set of sutures is passed at a right angle to the other, on twisting 
those of the perineum, tension would be exerted. This is a weak 
point, for if the tube is allowed to become obstructed, a small 
recto-vaginal opening will always result from the escape of flatus 
in this direction. I always scarify by means of scissors ; it can 
be done rapidly, and with less hemorrhage. The knees should be 
kept tied together ten days after the operation, and the urine 
drawn with care, so that none is allowed to escape over the sur- 
faces brought in apposition. 

" The sutures of the perineum are usually removed about the 
sixth day ; those within the vagina must remain for two weeks or 
longer, until the parts are strong enough to admit of the introduc- 
tion of a speculum. The bowels are to be constipated for two 
weeks at least in all cases where the sphincter has been lacerated. 
When the bowels are acted on by either a purgative or a warm 
mucilaginous injection, the success of the operation will greatly 
depend on the dexterity of the nurse in properly supporting the 
parts. 

" During the past ten years, in the hospital practice of Dr. Sims 
and my own, this operation has been uniformly successful. There 
has not been a single case of failure in uniting the sphincter and 
perineum by the first operation. I have, however, occasionally 
partially failed in private practice, where the laceration has been 
extensive, from a want of care in keeping the rectal tube unob- 
structed, or in not properly supporting the parts during the evacu- 
ation of the bowels, and necessitating a subsequent operation to 
close the rectal opening." 



CHAPTER II. 

DISEASES OF THE VULVA. 

Erythematous, papular, vesicular, and pustular inflammations 
of the vulva are not unfrequently observed, as are, also, squamous 
diseases. They resemble the same form of disease in other muco- 
cutaneous cavities and the skin, and hence, will not here claim a 
separate description. A disease somewhat more distinctive, how- 
ever, and yet resembling a disease of the mouth, is known as 
purulent vulvitis. This affection is characterized by severe in- 
flammation of the mucous membrane of the vulva, attended with 
minute points of ulceration, numbering from one to two dozen. 
The ulcers are small, an eighth of an inch in diameter, slightly 
excavated, and almost always covered with pus. The vulva is 
intensely red, and bathed in pus and mucus. The inflammation 
sometimes extends into the vagina and causes a copious flow of 
pus and mucus from that cavity. Not unfrequently the labia are 
very much swollen, and occasionally the deeper tissues are in- 
volved in phlegmonous inflammation. This form of inflammation 
is not unfrequently, in its early stages, attended with considerable 
febrile excitement. To a superficial observer, it strongly resembles 
gonorrhoea, from the swollen labia, burning pain, copious muco- 
purulent discharge, and the difficult and painful micturition. Its 
occasional sudden and unexpected development adds to this simili- 
tude, and legal proceedings have been instituted against parties 
supposed to have been instrumental in imparting the disease to 
little girls. It occurs in children generally from two to ten or 
twelve years of age, and probably results from want of cleanliness, 
heat, and local irritants, accidentally applied. If allowed to pursue 
a course undisturbed by treatment, other than cleanliness, it will 
generally subside spontaneously in two or three weeks, or in the 
course of that time become very much subdued, and run into 
chronic inflammation without ulceration. This last is often ex- 
tended into adolescence, and as vaginitis, gives origin to the leu- 



DISEASES OF THE VULVA. 33 

corrhoea of girlhood, and finally endometritis of the woman. It is 
sometimes attended with a debilitated and scrofulous constitution, 
indigestion, constipation, and ascarides ; but it is not likely origi- 
nated, though it is aggravated and fostered, by these attendant 
symptoms. 

The treatment is general and local. In the beginning, where 
the inflammation is high, it should be antiphlogistic and soothing. 
We may administer a mercurial cathartic, and quicken its action 
by a saline laxative, and after the bowels have been thoroughly 
moved, nitrate of potassa may be given internally, every three 
or four hours, in doses to suit the age of the patient. The parts 
should be frequently bathed or fomented with a decoction of poppy- 
heads, or with the watery extract of opium. In the course of 
four or five days the acute symptoms will begin to subside, when, 
in addition to attention to the bowels, we may administer an 
acid solution of quinine internally, and begin the use of astrin- 
gents locally. A solution of tannin, sulphate of zinc, aeetas 
plumbi, or other such astringents, weak at first, and afterwards 
increased in strength, may be applied freely to the parts four 
or five times a day. These remedies will generally remove the 
inflammation in a reasonable time. The astringents should be 
increased in strength to a sufficient degree for the purpose. If 
those mentioned are not strong enough, the chloride of zinc, sul- 
phate of copper, or even nitrate of silver, may be very properly 
resorted to. Should the inflammation extend into the vagina, the 
astringents may be injected into that cavity, by means of a small 
hard rubber syringe. We ought to be careful to use a very small 
syringe, and not to introduce it too far. The nurse should be 
carefully instructed in this kind of application. I feel impelled to 
insist upon the complete removal of the inflammation as early as 
it can reasonably be done, believing that if it continues until 
puberty, the inflammation extends into the body of the developing 
uterus, and entails a very distressing train of suffering upon the 
patient, that might have been avoided by an early and complete 
cure of the vaginitis. I am persuaded that too much importance 
cannot be attached to these views. 

Corroding Ulcer. — I have met with a number of cases of cor- 
roding ulcer of the vulva in children, which have been the 
cause of great suffering and apprehension. It occurs most fre- 

3 



34 DISEASES OF THE VULVA. 

quently in children, but is occasionally met with in adults. There 
is in each case usually but one ulcer, and it is most commonly 
situated on the lesser labia at first, and spreads to surrounding 
parts. The ulcer is ragged and irregular, not much excavated, 
with a dark foul-smelling covering, and the discharge from it is 
sanious, fetid, and excoriating. It is not generally rapid in its 
progress, and sometimes lasts for months, creeping from one part 
to another, until the anatomical features of the vulva are almost 
entirely effaced. I have not met with this form of disease except 
in very debilitated, sallow, and badly nourished persons. The state 
of the system leading to this sort of ulceration, I have thought to 
be more the result of living in poorly ventilated houses, particu- 
larly ; but coupled, also, with imperfect nourishment, or with 
nourishment of an improper character. 

It is generally obstinate, and yields slowly to judicious treat- 
ment. 

We should endeavor, as one of the main objects, to correct the 
constitutional condition as speedily as possible. To this end the cir- 
cumstances of the patient should be changed to the most favorable 
sort. Good ventilation at home, frequent and prolonged exposure 
to the fresh air, nourishing diet, of which animal food should be a 
large ingredient, and comfortable clothing, kept thoroughly clean, 
are indispensable to success. The bowels should be kept in as 
correct a condition as possible by gentle laxatives. The digestion, 
which is always feeble, if not otherwise faulty, may be improved 
by the administration of infusion of cinchona, quassia, or colomba, 
with the mineral acids ; the sulphuric being, perhaps the best. 
The chlorinated tincture of iron is also an excellent general rem- 
edy. The next thing to be accomplished is to convert the ataxic, 
half-sloughing, and corroding chronic ulcer, into an acute inflam- 
matory one. This is done by profoundly stimulating it with the 
stronger caustics. The one which has seemed to me to be most 
successful is the caustic potassa. It should be applied to the 
whole surface, by passing a stick, not very rapidly, all over it. 
After this burning, we may dress the ulcer with calamine ointment 
twice a day. This will almost immediately improve the condition 
of the sore. Unless there is some considerable firmness around 
and beneath it, in thirty-six or forty-eight hours after the applica- 
tion, caused by the effusion of fibrine in the submucous substance, 



DISEASES OF THE VULVA. 35 

not much good will result from it, and it will be necessary to resort 
to it or some other in a few days. The strong nitric acid is also 
very useful. I have not tried the actual cautery, but should ex- 
pect it to be very useful. We may often cure this ulcer by the 
weekly use of the solid nitrate of silver to it, dressing between 
times with lint saturated with black wash or calamine ointment. 
We ought not to be afraid of strong treatment, nor to continue it, 
or reiterate it in conjunction with a highly roborant general course 
of exercise, diet, and medication. 

Gangrenous Vulvitis, or Noma. — This is a very severe and 
generally fatal affection of the genital organs, occurring almost, if 
not wholly, among children. It may attack one or both sides 
simultaneously. In the few cases I have seen, there appeared a 
bleb or blister on the inside of the mucous surface of the labium, 
which at the same time became enlarged, hard, tender, and pain- 
ful. In a few hours the blister breaks, and from its side a not 
very abundant, but acrid serum is discharged. At this time a 
peculiar odor is emitted from the parts. All around the ash- 
colored surface, which represents the place where the blister was 
developed, the substance of the labium is very hard and much 
swollen. In two or four days the affected side is in a state of gan- 
grene, the discharge is very much increased, the parts upon which 
it runs are excoriated and inflamed, and an intolerable stench is 
exhaled. I have not seen an instance in which the gangrenous 
parts were cast off; the patients having died beforehand. Gen- 
erally, though not always, in the very beginning, the circulation 
and nervous system are very much disturbed. The pulse is quick 
and feeble, the patient nervously restless, or else stupid, the ex- 
tremities cool, the body — particularly about the pelvis — hot, the 
tongue furred, generally brown, and the skin dingy and sallow. 
As the disease advances the pulse becomes still more rapid and 
weak, the extremities cold, the mind wandering, and the restless- 
ness amounts to the frantic efforts of some sort of delusion. The 
tongue becomes dark-brown or black, the teeth are covered with 
sordes, and in the end, the patient sinks into profound collapse, 
and often coma, and dies. 

The disease runs its course sometimes in forty-eight hours, and 
again, in milder forms, it may last five or six days. The causes, 
although unknown, must undoubtedly be of a depressing nature, 



36 DISEASES OF THE VULVA. 

overwhelming the organism very rapidly. It occurs sporadically, 
when it is comparatively mild, and epidemically when severe. In 
this last state it is very rapidly fatal. 

The prognosis is very bad, as it is always, or pretty nearly 
always, fatal. The profession, so far as I am aware, has not de- 
cided whether the disease is a general one, and the affection of the 
genital organs an incident, or whether the local disease inaugu- 
rates the general symptoms. The former is most likely the truth- 
ful interpretation of the phenomena. 

In such a disease there is but little prospect of a cure by treat- 
ment ; we should, nevertheless, institute a course clearly indicated 
by the symptoms and signs. The general treatment should be 
strongly stimulant, tonic, and supporting ; quinia, brandy, tinc- 
ture of cantharides, and beef essence, as much as the patient can 
bear, should be administered. I do not think the strong caustic 
local treatment, generally advised, any better, if as good, as the 
charcoal and yeast poultices, chloride of lime, anodyne fomenta- 
tions, and cleanliness. Much attention should be devoted to 
thorough ventilation, isolation of the patient, and the neutraliza- 
tion of the fetor by disinfectants. 

Pruritus Pudendi. — A very annoying, and often obstinate affec- 
tion of the genital organs, is an inordinate itching of the vulva. 
The itching returns by paroxysms. The patient will sometimes 
be free from it except when standing by a warm fire, or becoming 
heated by exercise, passion, &c. Or she may be affected only for 
a short time before, at the time, and after menstruation. Again, 
the paroxysms return without any apparent reason. The sensation 
sometimes is that of a burning glow, attended with an irresistible 
desire to rub or scratch the parts, a desire which the most delicate 
sense of propriety cannot always keep within due bounds. At 
other times the sensation is such as might be produced by the 
crawling of pediculi, and the patient is assured that thousands of 
these animalcula are moving upon her person, and will be con- 
vinced to the contrary only by inspection. This sense of formi- 
cation, although very disagreeable, is a slight inconvenience com- 
pared to the sufferings of the other variety. 

The former variety is almost always attended with inflammation 
of the mucous membrane of the vulva. The accompanying in- 
flammation may be simply erythematous, papular, or vesicular. 



DISEASES OF THE VULVA. 37 

Dr. Dewees describes a variety of vesicular inflammation resem- 
bling aphtha, attended with pruritus. I am sure that the papulae 
or vesiculae are neither of them always present in very distressing 
cases of this affection, although I have not seen it when the parts 
were not in some way inflamed. It may be observed that, in 
the formication variety of pruritus, the itching is generally most, 
if not wholly, confined to the cutaneous surface of the labia. It 
will be inferred that I consider pruritus but a symptom of several 
diseased conditions, generally of the genital organs, but sometimes 
it undoubtedly may be caused by the state of the intestinal tube, 
particularly the rectum, or some other remote condition. An 
intelligent scrutiny of the cases as they arise, will most frequently 
result in the discovery of the originating condition. It is often 
an obstinate affection, 'lasting for weeks, months, and even years 
in bad cases, but more frequently it is amenable to treatment, 
and a judicious course will be rewarded by success. 

Treatment. — The first thing to be done is to remove the cause, 
when practicable. In order to do this, the abdominal organs will 
require attention. The sluggish secretions and bowels must be 
corrected by alteratives and laxatives. A mercurial, say five 
grains of massa hydrarg., may be given at night, to be followed 
in the morning by a saline laxative, sufficient to cause one or two 
stools. This may be repeated at intervals of from one to four 
days, until the object is gained. Meantime, if the stomach is 
weak and digestion imperfect, the bitter infusions, with alkalies or 
acids, as the condition may require, will be demanded ; and should 
the patient be anaemic, iron may be given. As is sometimes the 
case, the patient will be plethoric, when the alteratives, with spare 
diet, will do better. With the above treatment, if the health be 
faulty, or without, if this is not the case, we will generally be 
obliged to resort to local remedies. And first of all is cleanliness. 
The parts, externally and internally, must be subjected to thorough 
and frequently repeated ablutions. The syringe may and should 
be brought into use for this purpose from three to a dozen times a 
day. The water used for ablutions may be impregnated with sal 
soda, very appropriately, or some fine toilet soap. I have found 
much advantage, when there was no eruptive accompaniment, 
from 3ij tinct. ferri chl. in a quart of water, three or four times 
a day. This is especially useful when there is leucorrhoea, and a 



38 DISEASES OF THE VULVA. 

congested, dark appearance of the mucous membrane. When there 
is a vesicular eruption, the recommendation of Dr. Dewees, to 
sprinkle the parts with pul. sodse biboras, and keep them ex- 
posed as much as possible to the air, will be of great service. 
Prof. Simpson uses chloroform in the forms of vapor, liniment, or 
ointment, with good effect. The infusion of tobacco, applied freely 
two or three times a day, is recommended by the same author. 
When the mucous membrane is much inflamed, a solution of hydro- 
cyanic acid, ten drops to the ounce of water, often gives great 
relief. A strong solution of tannin and aqueous extract of opium, 
is also applicable to this class of cases. An excellent palliative 
is pure glycerine. It may be introduced into the vagina by 
saturating a plug of cotton with it, and passing it up through a 
glass speculum and allowing it to remain there for ten or twelve 
hours. We should take the precaution to attach a thread or cord 
to the cotton so that it may be readily removed. One of them 
introduced every twelve or twenty-four hours is often enough 
generally. We should also apply it between the labia in the same 
way. As explained by Dr. Sims, who first recommended its use, 
the glycerine induces copious serous depletion from the congested 
mucous membrane, thus relieving it. 

In cases of some duration, I have often been enabled to produce 
a decidedly favorable change by applying the tinct. ferri chl. in 
full strength with a brush once a day to all the mucous membrane 
of the vulva, and as far in the ostium vaginae as I could pass the 
hair brush. The first burning sensation is succeeded by great 
amelioration of the sufferings, and finally, in many cases, by a 
cure. When this fails, we may sometimes succeed by making a 
similar application of a solution of nitras argenti, in the strength 
of 5ss. to Sj of water. This last application should not be used 
oftener than once in two days. In the use of all these remedies, 
we must not lose sight of the ablutions, nor fail to search for par- 
ticular local causes, and try to remove them. As has been very 
judiciously remarked by Prof. Simpson, we will find great advan- 
tage in alternating the use of appropriate remedies, instead of 
using the same kind all the time. The obstinacy of this affection 
will require great patience in many instances, as well as ingenuity 
in using remedies. 



DISEASES OF THE VULVA. 39 

Urethral Excrescences. — Caruncles of the urethra. Vascular 
tumor at the orifice of the urethra. 

These names have been given to small tumors springing from the 
mucous membrane of the vulva, immediately round the urethral 
orifice, or from the lining of the urethra itself. They are generally 
solitary, but sometimes there are several. Sometimes they are 
sessile, and seem to be a hypertrophied fold of the mucous mem- 
brane of the orifice ; at others, they are polypoid in their attach- 
ment. In size, they vary from a pin's head to a small nut. They 
also vary in their appearance. As before remarked, they some- 
times resemble in color, consistence, and polish, the mucous mem- 
brane upon which they are planted ; while in other cases they are 
quite red, almost scarlet, very soft, and easily broken. They 
diifer in their anatomical properties quite as much as in appear- 
ance, seeming, in some instances, to have no more vessels and 
nerves than other portions of the neighboring tissue; while at 
others, they are formed mostly of capillary bloodvessels and loops 
of nerves. They are a morbid development of existing tissues, 
instead of a growth of abnormal substance. These tumors are 
often observed, particularly the more dense and light-colored 
varieties, without giving origin to any symptom that would lead 
to their detection; on the other hand, in many instances they often 
produce the most excruciating suffering. The kind of caruncle 
that has seemed to me to be the important one, is the blood-red 
tumor projecting from the mouth of the urethra, and attached by 
a small neck. A few weeks since, I met with one of these of cres- 
centic shape, attached by a neck that arose from the concave 
margin, and had its other attachment inside the urethral orifice. 
It would not have weighed two grains, but it caused agonizing 
symptoms. It must not be supposed that all of the varieties will 
not occasionally cause great pain. The symptoms of their pres- 
ence are almost always connected with the evacuation of the blad- 
der, and attempts to handle the part. The passage of urine 
causes the most excruciating suffering from pain and tenesmus, 
the patient often straining for several minutes after the complete 
discharge of the urine. The slightest touch, also, is the cause of 
great pain. The diagnosis cannot be clear without an ocular 
examination. If the parts are exposed to a good strong light, 
and the labia separated, the excrescence will be at once discovered, 



40 DISEASES OF THE VULVA. 

unless it be quite inside the urethra. If any doubts exist, we 
should introduce the finger in the vagina, and press the urethra 
forward. It is difficult to say, with truthfulness, what are the 
causes of these caruncula. My cases have been in patients obvi- 
ously deficient in cleanliness. This seems to have been the case 
in that which came under Dr. West's observation. 

The treatment is simple, and consists in two main objects: 1st, 
the removal of them ; and 2d, the production of a profound im- 
pression upon the point of origin. In fact, the tissues from which 
they spring should be destroyed to a slight depth. The first ob- 
ject may be most readily gained by snipping it off with scissors; 
and the second by holding caustic potassa, or the actual cautery, 
to the place until the virus is destroyed. 

Vascular Urethra. — Analogous to the caruncle is the vascular 
urethra. It gives rise to the same train of symptoms, though not 
so intensely distressing, and is very persistent. It occurs more 
frequently in patients near the climacteric period, although I have 
seen it in much younger persons. When the labia are separated 
and the parts exposed to a good light, the urethra is seen to be 
patent, and the tissues around the orifice swollen and of deeper 
hue than usual. The mucous membrane of the urethra is of an 
intensely scarlet color, and, upon minute inspection, the vessels 
may be seen enlarged ; it is very tender and sensitive to the touch, 
slight contact producing exquisite pain. There is great burning 
and sense of cutting when urine is voided, and all the symptoms, 
even the sympathetic nervous derangements, attendant upon car- 
uncle. This condition is not incipient caruncle, for there is no 
elevation, no protrusion, and the condition lasts for years without 
material change of substance. The treatment I have found most 
effective, is strong nitric acid or caustic potassa applied cautiously 
to the membrane inside the urethra. 

I have not tried the actual cautery, but believe it would be very 
effective. An application of the acid on a piece of lint moistened 
by it, to the whole membrane in sight every ten days, for two or 
three times, generally is sufficient ; sometimes once only is re- 
quired. 

Hypertrophy of the Clitoris and Nympha. — It is very rare that 
we meet with hypertrophy of these organs without morbid change 
in the tissues. There is either cystic development in their sub- 



DISEASES OF THE VULVA. 41 

stance, or degeneration of the membranous tissues. The two dis- 
eases that would seem to contribute most frequently to this en- 
largement, are syphilis and elephantiasis. In either case the de- 
generation is in the mucous membrane almost exclusively. The 
size is sometimes but slight, and sometimes very great, making a 
tumor from the size of a pigeon-egg to a volume long enough to 
reach to the knees. The surface is generally rough, uneven, nodu- 
lated, and sulcated. From exposure and friction they are almost 
always excoriated, and give origin to an ichorous irritative dis- 
charge, that produces inflammation in the skin round about. These 
tumors are always a great annoyance, and sometimes very mate- 
rially impair the general health. There is but one eligible means 
of relief from these disgusting enlargements, and that is amputa- 
tion. Fortunately it is an easy and safe operation. The parts 
are included in the coil of the ecraseur, and slowly crushed off. 
Where the enlargement extends to all the parts, the clitoris may 
be operated on first, and then each of the nympha separately am- 
putated. This instrument is much better for these operations 
than the knife, as there need be no apprehension of hemorrhage. 
If the hypertrophy is simple there will' be the same necessity for 
amputation, as the like inconveniences will almost surely arise as 
in the morbid variety. 



CHAPTER III. 

STONE IN THE BLADDEE. 

Vesical calculus in the female is of very rare occurrence, ab- 
solutely and relatively. Of all the cases of calculus vesical, only 
about one in twenty is met with in the female sex. This may be 
accounted for from the size, straight form and dilatability of the 
urethra, and consequent direct escape of small sanguineous and 
mucous accumulations, and even sandy concretions. Indeed, quite 
large stones are expelled through the urethral canal, making their 
way out, in some instances, in a few moments with acute suffering, 
while in others they are many hours in forcing a passage. It 
would seem that these hard substances are evacuated more readily 
during the state of pregnancy, than at any other time ; doubtless, 
because of the urethra partaking in the general increased dilata- 
bility of the genital organs which precede labor. 

Symptoms. — There are probably no symptoms attendant upon 
stone in the bladder in woman, but is produced more frequently 
from other causes, hence they are quite unreliable, and can be 
taken only as suspicious instead of diagnostic evidence of its pres- 
ence. They are great and persistent irritability of the bladder, 
severe pain after voiding the urine, sudden cessation of the flow 
while there is yet a desire to urinate, and evidently some fluid in 
the organ, enlargement or relaxation of the urethra, and inconti- 
nence of urine. The urine is also charged with mucus, pus or 
blood, or all three of these in greater or less quantities. The 
symptoms will be more strongly marked if the calculus is rough 
and jagged in shape, and less so if the surface is smooth and even. 
All these symptoms are not present in any given case, but some 
of them are certain to be prominent and very distressing. 

Diagnosis. — The only way to positively determine the diagnosis, 
is by physical examination of the cavity of the bladder. This is 
done by means of the fingers and the sound. If two fingers be 
passed deeply into the vagina, as far as the cervix uteri, the 
most dependent part of the bladder may be pressed strongly up 



STONE IN THE BLADDER. 43 

against the internal face of the pelvis, or lower portion of the an- 
terior abdominal wall. If this latter be pressed well down into 
the pelvis with the other hand, while the fingers are still in the 
vagina, careful manipulation will scarcely fail to distinguish a 
calculus of moderate size. When the bladder is full of water, if 
the calculus is large, it may be raised and its presence pretty con- 
clusively determined by ballottement. The stone is felt, however, 
more distinctly through the urethra by the sound, the same as it 
is used in the male. The operation may be facilitated by the 
fingers in the vagina moving the stone around. The same diffi- 
culties in preventing or making difficult and perfect diagnosis are 
met with, as in the male, if the stone be encysted or adherent to 
the upper or anterior wall of the bladder ; but if the instrument 
is sufficiently curved and moved about in various directions it will 
be detected ; its position and size ascertained with more precision 
and certainty than in the male. 

Treatment. — The only means of relief available is the entire 
removal of the calculus. This may be done by dilating the ure- 
thra, and extracting through it, by lithotomy or lithotrity. All 
these operations are less hazardous in the female than in the male, 
in fact, we scarcely take the subject of danger to life into consid- 
eration in operating for stone on a woman, but one very great in- 
convenience likely to follow dilatation of the urethra and lithotomy 
is incontinence of urine, and the attention of recent operators is 
turned mainly to the matter of avoiding this most distressing se- 
quel. The preference is given by some surgeons to lithotomy, be- 
cause they think this evil less frequent after it, while for the same 
reason others resort to dilatation of, and extraction through, the 
urethra. Very few now practice lithotrity in the female, and 
this operation is looked upon as attended with more hazard than 
either of the others. It is astonishing with what facility the fe- 
male urethra may be largely and rapidly dilated. I have seen it 
stretched so as to admit the index finger in ten minutes without 
violence to its integrity. Where the stone is not very large — over 
an inch in diameter — we may expect to succeed by dilatation with- 
out much damage, if the proper caution and gentleness are used. 
When the stone is much larger, and especially if it is rough, we 
should cut. The operation of dilatation is simple. It may be 
performed by compressed sponge, Weiss dilators, or bougies. The 



44 STONE IN THE BLADDER. 

sponge is very rough and almost intolerable, and slower in its ac- 
tion than the instrument. If we use the sponge it should be in- 
serted as much as six to ten hours before the time to operate. The 
patient should have a full dose of opium, and be under its influence 
before the sponge is used, and we will succeed much better if she 
is rendered insensible by chloroform. The sponge when com- 
pressed ought to be a little larger than a female catheter, three 
inches long, and slightly conical in shape. It should have a per- 
foration reaching two-thirds or three-fourths the length of it, from 
the base toward the pointed end. After the patient is prepared, a 
strong sound or staff is passed as far in the perforation of the 
sponge as it will go. With the sponge thus mounted upon the 
sound it should be passed slowly but firmly through the urethra 
until one end is in the bladder. If this can be endured for six 
hours, the sponge may be removed, and the urethra will be large 
enough generally to admit the finger. The sponge, I think, is less 
likely to rupture the fibrous structure than any other means of 
dilatation now in use. 

A less painful mode, and one next in safeness, is performed 
with graduated bougies. After the patient is under the influence 
of the anaesthetic, a bougie large enough to require some force to 
introduce should be passed into the bladder, and allowed to remain 
in the urethra for from two to five minutes. This should be fol- 
lowed by one a size larger, and so on until the canal will admit 
the finger. One advantage of this mode is that the distension is 
uniform all around the urethra. If the dilator is used the blades 
are passed folded together, and then separated so slowly as not to 
tear the tissues. Whatever means we use to dilate with, they 
should be laid aside so soon as the finger will enter the canal, and 
further dilatation effected by this means until there is room for 
the introduction beside it of a small lithotomy forceps, with which 
to apprehend the stone. Soon as the finger can be made to enter 
freely the bladder, other fingers should be passed into the vagina, 
and caused to press the stone forward so that its size, shape, 
consistence and the character of the surface be ascertained. If 
there is a long diameter, the end must be directed to the urethral 
opening, and retained with as much security as may be, until the 
forceps are introduced and the stone seized. Traction should be 
made in the direction of the urethra with the instrument, while 



STONE IN THE BLADDER. 45 

with the fingers in the vagina the efforts may be governed so as 
to keep up the right direction and steadiness, and also to push the 
stone into the urethra. Swaying the instrument in different di- 
rections, and performing slight rotation, the force used should be 
very gently applied and slowly increased, giving the parts time to 
stretch, and no more exerted than is just sufficient to accomplish 
the extraction. We should not be in a hurry, but take plenty of 
time ; more damage is done by too great hurry than too great di- 
latation, I think. The parts are torn instead of being stretched. 
If the stone is too large to be removed in this way, which will be 
very seldom indeed, we may perform lithotomy, or the mixed 
operation of cutting and dilating. There are several methods of 
performing lithotomy in the female. 

Dr. Sims has proposed and performed lithotomy through the 
vesico-vaginal septum. He exposes the parts as for operation 
for vesico-vaginal fistula, introduces a curved director through 
the urethra, and cuts into the bladder upon it until the opening is 
large enough to permit the stone to pass. The finger is then 
passed through the artificial opening by which the forceps is 
guided, the stone seized and extracted through it. The wound is 
then closed with silver sutures, and the patient otherwise treated 
as for fistula. In experienced hands this must be a pretty and 
complete operation, but the young operator will hesitate very 
properly to substitute this for dilatation. The operation for lithot- 
omy and dilatation combined is more simple, and easily effected by 
the inexperienced. A grooved director is passed into the urethra 
until the end of it enters the bladder, with the groove directed up 
to the arch of the symphysis pubis. A straight, long, narrow, blunt- 
pointed bistoury is placed with the back of the blade in the groove, 
the blade touching and parallel to the director in its whole length, 
and then urged forward until it enters the bladder. This will be 
known when the sensation of dividing tissue ceases to be experienced. 
This should be done slowly and no more division made than will 
be caused by simply passing the blade along the groove. When 
this is accomplished the instruments are withdrawn, and the canal 
dilated to any necessary extent w T ith the finger. The rest of the 
operation is performed as in the case of dilatation and extraction. 
A few days' rest on the bed, and as much opium as is necessary to 
keep the pain from being excessive, will suffice to restore the pa- 
tient to health. 



CHAPTER IV. 

VAGINITIS. 

Acute Vaginitis begins generally in the lower part of the va- 
gina, with swelling, intense redness, and dryness of the mucous 
surfaces of the labia, vulva, and vagina. There is great heat in 
the parts, and the patient complains of burning pain in them. 
Difficult, painful micturition, pain in passing the faeces, sense of 
weight in the pelvis, and tenesmus, are generally present also. 
Not unfrequently there is backache and pain, radiating down the 
thighs, into the hips, up the spine, and into the head. Sometimes 
the symptoms are so acute as to produce general febrile disturb- 
ance. When this is the case, there is chilliness alternating with 
heat, more or less increase in the frequency of the pulse, furred 
tongue, pain in the limbs, &c. In the course of thirty-six hours, 
the pain, redness, and swelling have spread to the whole of the 
vaginal cavity, and soon there is a profuse secretion of mucus, 
which, after two or three days, or even sooner, is mixed with pus- 
globules in greater or less abundance. When this last is the case, 
the discharge is either green or yellowish in color, and less tena- 
cious. This state of things lasts for from ten to twenty days, 
when the inflammation gradually subsides, the discharge becomes 
less in quantity and lighter in color, until in four or five weeks the 
disease is entirely gone, or it merges into the chronic form. The 
inflammation usually involves the urethra, and sometimes the 
bladder, and its greatest intensity is almost always in the lower 
third of the vaginal canal. The inflammation sometimes spreads 
to the rectum. Sometimes it attacks the mucous membrane of the 
cervix uteri, and even invades the cavity of the corpus uteri, re- 
maining longer in these localities than in the vaginal cavity. 

Diagnosis. — The diagnosis of acute vaginitis is not difficult, as 
the parts may be easily seen and touched. 

Prognosis. — As has been heretofore intimated, it subsides spon- 



ACUTE VAGINITIS. 47 

taneously, and leaves the parts free from disease, or in a state of 
chronic inflammation. The prognosis, therefore, is favorable. 

Cause. — It is caused by contagion more frequently, perhaps, 
than anything else, but does doubtless arise from abuses, injuries, 
and want of cleanliness, and probably other causes. I have seen 
the non-contagious form in children very much more frequently 
than adults, spreading usually from the vulva upwards. Simple 
acute vaginitis is not a very common affection. At first it involves 
the mucous membrane and submucous tissue, but before many days 
it is confined to the membrane alone. 

Treatment. — This at first should be slightly antiphlogistic. A 
few grains of calomel, followed in ten or twelve hours with a saline 
cathartic, should be the first step. This may be succeeded by 
nauseating doses of ant. et pot. tart., until the dryness and swell- 
ing have subsided. In the meantime, perfect quietude in the re- 
cumbent position should be enjoined, the parts bathed every hour 
or two thoroughly with tepid water, and the patient should abstain 
from stimulating or nutritious ingesta. So soon as the discharge 
has become copious, and yellowish or green, and the swelling of 
the parts has entirely subsided, the treatment should be changed 
for astringents, specifics, laxatives, and baths. We may give half 
a drachm of balsam copaiba in emulsion or capsules every six or 
eight hours, and have the vagina syringed copiously with a satu- 
rated solution of alum, or acetate of lead, two or three times in 
twenty-four hours. Every third day a few ounces of solution of 
argent, nit., in the strength of ten grains to the ounce, may be 
advantageously used. The bowels should be kept open, and the 
patient should abstain from stimulants at all times during the 
treatment. The astringent injection ought to be changed every 
five or six days, using alum, sugar of lead, and sul. zinc, alter- 
nately. Perseverance in this treatment will very materially shorten 
the course of the disease. 

Chronic Vaginitis. — This is a more frequent form of disease 
than the acute, and its importance will be understood from this 
consideration. It is in many instances a very distressing affection, 
and often mistaken for diseases of the uterus, bladder, or rectum. 

Symptoms. — There is generally pain in the back, more frequently 
in the sacrum and coccyx, but not seldom higher up ; pain in the 
groin, weight and sense of bearing down in the perineum, drag- 



48 CHRONIC VAGINITIS. 

ging in the hips and pelvis. A burning sensation in the vagina, 
extending all over the lower part of the person, very distressing 
and depressing, is sometimes the chief symptom complained of by 
the patient. In married patients it is the cause of distress during 
the act of coition, to such a degree, sometimes, as to entirely pre- 
clude such indulgence. I am now treating a patient who assures 
me that although she has been married fifteen years, she does not 
remember a single instance of sexual intercourse that did not give 
her discomfort; generally it is the cause of decided pain, and 
sometimes entirely intolerable to her. Leucorrhcea is a common, 
but not invariable symptom ; it may be yellow or white in color, 
but when the case is not complicated with cervical inflammation 
it is always thin. In chronic vaginitis there is generally a long 
train of sympathetic symptoms not unlike those observed in dis- 
eases of the uterus. The nervous centres are disordered in their 
functions, and we have nervous symptoms of almost every de- 
scription. The mind is sometimes affected by it to irascibility, 
despondency, suspiciousness, peevishness, and purposeless insta- 
bility. In other, or, perhaps, the same cases, there is palpitation 
of the heart and large vessels to such a degree as to cause alarm 
for the life of the patient. Headache should be mentioned as 
quite common ; it is more commonly located in the occipital re- 
gion, but may be in the top, forehead, temples, or all over the 
head. The eyes are generally weak. The stomach is frequently 
deranged to a considerable extent, and in various ways ; and there 
is generally a constipated state of the bowels, though diarrhoea is 
an occasional symptom. There often is pain, too, in urinating, 
and in passing the fseces through the rectum. The uterus is 
almost always affected, also, and through it the symptoms may 
become greatly diversified and increased. We should expect this 
complication. 

Diagnosis. — Upon examining the vagina, the introduction of 
the finger will give some pain, sometimes a good deal, and the 
speculum causes a great amount of suffering. There is general 
redness of the mucous membrane ; it is usually bathed in its own 
mucous secretion; sometimes it is so raw as to bleed upon the use 
of instruments in making the examination. The sensitiveness, 
redness, and exaggerated secretion, are conclusive and diagnostic 
symptoms when they are permanent. 



CHRONIC VAGINITIS. 49 

Causes. — Chronic vaginitis is often the result of an acute at- 
tack. The inflammation only partially subsides at the time, and 
is continued indefinitely. Some of the most obstinate cases I 
have met with have thus resulted from gonorrhoea. Another set 
of cases are seen in patients whose husbands were the subjects of 
syphilis in early life, but to all appearance have been cured. I 
am inclined to the opinion that chronic vaginitis is not an uncom- 
mon occurrence in women thus situated. It is more likely to fol- 
low recent cases of syphilis, and is sometimes subacute in grade. 
Another form is apparently produced by abortions, colds, and 
other causes, with, at the same time, inflammation of the cervix 
uteri. Constipation, causing sluggishness of the vaginal circula- 
tion, or any other causes producing this vascular condition, as the 
pressure from pelvic tumors, phlegmonous effusion, &c, contribute 
to the causes of chronic vaginitis. There is no doubt but that 
certain constitutional taints, as scrofula, rheumatism, and, as before 
intimated, syphilis, are efficient co-operating causes. 

Prognosis. — Chronic vaginitis, in its simpler forms, is apt to be 
obstinate, and resist judicious treatment for years. It is more 
particularly so when originating in constitutional diseases. When 
connected with incurable tumors, it will, of course, resist all sorts 
of treatment. 

Treatment. — The constitutional treatment of chronic vaginitis 
is sometimes of the first importance, while at other times it is un- 
necessary, or nearly so. The variety which seems to be connected 
with the syphilitic condition, requires the alterative remedies 
which are found beneficial in this affection under other circum- 
stances, — the preparations of mercury, iodine, and the vegetable 
alteratives, for instance. When associated with scrofula, the 
vegetable tonics, with alterative treatment, plenty of outdoor ex- 
ercise, cod-liver oil, and cold bathing, sea bathing, &c, will be ap- 
propriate measures to be employed. As it is not unfrequently 
complicated with rheumatism, or this diathesis, it may be necessary 
to prescribe for it with such consideration. 

But in more simple cases, where there is no such taints or com- 
plications, conditions exist that require a judicious course of gen- 
eral treatment for their removal, before we can be successful in 
our main object. Such is a torpid state of the bowels and portal 
circle, with scanty secretions. Mercurial and saline laxatives, 

4 



50 CHRONIC VAGINITIS. 

vegetable tonics, as the bitters, also alkalies, will, when judiciously 
used, assist us very much. We should be particularly careful to 
avoid a loaded or impacted state of the rectum, as this is the cause 
of much vaginal congestion. An injection once or twice a day, 
when necessary, will suffice for this. 

In all forms, in addition to the general treatment, when that is 
necessary, we will be under the necessity of resorting to local 
measures. Much benefit will be derived from a sitz bath twice a 
day. The bath should be tepid, as a general thing, as being more 
likely to agree with the largest number of patients. When it is 
more agreeable, the bath may be cooler. It should be large 
enough to cover the hips, and the patient should remain in it for 
an hour at least, and often it is better to use it for a greater 
length of time. Of more importance are injections. Simple 
water in large quantities is sometimes sufficient, but more fre- 
quently astringent substances* will be found essential. The injec- 
tions should be administered through a perpetual syringe, and the 
quantity should be large, say from one quart to a gallon of water 
at each time. The common astringents, as alum, sul. zinc, acet. 
lead, of the strength of one drachm to the quart of water, will 
generally suffice. We find cases, however, in which none of these 
substances can be used, because they disagree with the patient, 
producing dryness of the parts or increasing the inflammation. 
In such cases we must carefully search for the right local remedy. 
We may find it in tannin, tr. iron, perchl. of iron, astringent de- 
coctions, nitrate silver in solution, &c. The last, used once in four 
or five days, with a glass syringe, and the other astringents be- 
tween, often proves to be the best course. 

An excellent and very convenient mode of applying medicinal 
substances to vaginal surfaces is to make small sacs of domestic 
or linen and fill them with the substance intended for use, and intro- 
duce them into the vagina. A sac the size of a small glove finger, 
with a piece of thread attached to it, will hold an abundance of 
almost any remedy we desire to use. Tannin in powder or oint- 
ment, gall ointment, belladonna ointment, and other articles are 
used in this way. A mixture I have used very commonly consists 
of two drops of creasote, half drachm of tannin, and one grain 
of belladonna extract, introduced at bedtime each night. The 
little bag may be removed in the morning by traction on the string. 
There are, I think, some advantages in the use of these little bags 



PUERPERAL VAGINITIS. 51 

over the other sorts of medicated pessaries used. I not unfre- 
quently inclose copavia capsules in these little sacs, and think it 
an admirable mode of making balsamic applications to the vaginal 
mucous membrane. Where the astringents or other remedies are 
thus used they will not replace the injections wholly. Indeed the 
vagina should be well washed out before the introduction, and at 
the time of the removal of them. Patients of course can manage 
these application without aid. 

Perseverance and time are important items in the treatment- 
If we can remove this chronic inflammation in three or even six 
months, we ought to be satisfied. And we ought not to be sur- 
prised to have it return one or more times after it is apparently 
cured. It is well, also, to teach our patient patience in this re- 
spect. 

Puerperal Vaginitis. — It might not seem necessary to consider 
the vaginitis occurring after labor as a separate affection, but there 
is so much difference, — in the causes, nature, symptoms, and ter- 
mination, — between ordinary vaginitis and this form, that I think 
it may be profitable to do so. In some cases of labor, circum- 
stances occur that induce a severe form of inflammation of the 
vagina. The one most potent is long detention of the foetal head 
in the pelvis. The pressure thus exercised upon the vaginal walls 
interrupts the circulation more or less completely ; and if continued 
for a number of hours, violent reaction in the parts result when 
the pressure is removed. This pressure does not affect the mucous 
membrane of the vagina so deleteriously as the deeper-seated 
tissues. The fibro-cellular part of the vaginal walls is the seat of 
the inflammation. I do not think the use of instruments, however 
awkward, does so much damage as the long-continued pressure. 
It must not be denied, however, that instruments do give origin to 
this form of inflammation. When they do so, the inflammation is 
more circumscribed ; it does not extend to all parts of the vagina, 
as is apt to be the case when pressure by the child's head has been 
the cause. On account of the nature of the causes, this form of 
vaginitis runs its course rapidly, and is most sure to end in struc- 
tural lesions. It is in intense forms of this sort of vaginal inflam- 
mation that sloughs and deep ulcerations are met with, which open 
the bladder and cause vesico-vaginal fistula, recto-vaginal fistula, 
and cicatrices, which result in contractions and even occlusions 
of the vagina. It is astonishing how much destruction sometimes 



52 PUERPERAL VAGINITIS. 

is effected by intense post-partum inflammation. I remember being 
called to a case in consultation where the child's head had been 
pressing down sufficient to bulge the perineum and labia for sixty 
hours without any motion. I delivered her with the short forceps 
in a few moments, without any violence to the parts. The patient 
was then unavoidably left in the hands of the same careless prac- 
titioner that had so outrageously neglected her before the delivery. 
I saw her three months afterwards, and found the whole septum 
between the bladder and vagina gone, the urethra terminating 
abruptly, as though it had been cut straight across, in a great 
irregular cavity, that was bounded by the pubis before and the 
uterus behind, and without any defined sides to it. In still a 
worse case, where shoulder presentation had prevented the passage 
of the child, the woman was in the second stage of labor six days. 
The woman arose from her bed with a large undefinable cavity, — 
without any bladder, apparently, but the very top portion,— and 
the loss of two inches of rectum, into which the urine and faeces 
were poured involuntarily. In more than one instance I have seen 
the whole vagina sealed up, from the fourchette to the urethra, and 
as far up, as well as I could judge, to the os uteri, as the effect of 
intense and neglected puerperal vaginitis, arising from unaided 
difficult labor. Every practitioner must meet with cases in which 
the cavity of the vagina is misshaped, and partially closed, from 
the cicatrices resulting from it. Now, much of these direful effects 
may be averted by the rational management of inflammation after 
it has been initiated. 

Symptoms. — When injurious pressure has awakened inflamma- 
tion in the vagina, the labia and walls become swollen, hot, and 
very tender. The patient does not generally complain of much 
severe pain, but there is a sense of soreness and heat. There is 
almost always fever, chilliness, and other evidences of disturbance 
to the circulation ; the tongue is coated, ordinarily white, some- 
times yellow, or even brown, from the beginning. As the disease 
advances two or three days from the beginning, the discharge from 
the vagina becomes more than ordinarly fetid, the labia excori- 
ated, while the heat of the vagina is still very great, and there is 
much mucus and some pus issuing from it ; and later, shreds of 
decomposed substances, and sometimes considerable sloughs, are 
mingled with the discharge, increasing the fetor. The pulse is 



PUERPERAL VAGINITIS. 53 

more accelerated, and sometimes becomes quite rapid; the patient 
is much prostrated ; the tongue brown and dry, and the teeth foul 
with a dark clammy mucus, while the skin is bathed in a copious 
perspiration. In from two to six or eight days, to these symp- 
toms are added an evacuation of urine through the vagina, at first 
in small quantities, and afterwards more considerable, until, in a 
short time, the contents of the bladder are passed through this 
way ; the parts around are excoriated by the urine and other acrid 
discharges, and a slow, uncertain convalescence succeeds, with a 
permanent vesico-vaginal fistula. Occasionally, though not so fre- 
quently, the faeces pass through the vagina after a few days from 
the beginning of the inflammation, and we have a recto-vaginal 
fistula. If neither of these evils occur, there is extensive ulcera- 
tion, not so deep, but extending over a large surface of the va- 
gina ; thus pus and acrid ichor are poured out in copious quanti- 
ties, for a long time, gradually decreasing as the surface heals. 
As these ulcerations heal up, the. tissue becomes condensed and 
contracted, until such strictures or occlusions result as are above 
mentioned. The practitioner should be wide awake to this fre- 
quent course of post-partum vaginitis. 

Treatment. — As most damage from this form of vaginitis usually 
accrues to the bladder and rectum? our first and most solicitous 
care should be bestowed upon them. The bladder should be fre- 
quently emptied with the catheter ; at least every four hours the 
urine must be drawn off. To appreciate this direction, we have 
but to remember that this organ may be considerably distended in 
that time, and as the septum between the vagina and bladder is in 
a state of intense inflammation, it is softened, and therefore is 
easily ruptured. My impression is that fifty per cent, of the 
vesico-vaginal fistulse which now occur might be avoided by fol- 
lowing this rule. Its importance cannot be over-estimated. In 
very bad cases the catheter might be used even more frequently, or 
kept in the urethra. The rectum should be kept free from any 
accumulation of faeces by frequent injections of tepid water. In 
addition to this prevention against fistula, the utmost cleanliness 
must be observed. The vagina should be washed out with soap- 
soads or other bland detergent fluid, from four to six times a day. 
For the first four or five days the parts may be kept lubricated 
thoroughly by the injection, after the water, of very bland sweet 



54 PUERPERAL VAGINITIS. 

oil, or almond oil. When the slough begins to be thrown off, or 
pus and sanies become copious, an injection of half a pint of tepid 
water, containing six or eight drops of creasote, twice a day, will 
serve to cleanse and stimulate the parts better than soap and 
water alone, which should be used between times. After the lapse 
of a week or ten days, if the ulceration is not healing, an injection 
of ten grains nitrate of silver to the ounce of water may be used 
quite advantageously. This solution should be injected from a 
hard rubber or glass syringe, directed to the ulcerated part by the 
finger. As the case still further advances, a solution of tannin, 
alum, sulphate of zinc, or other astringents, with the detergents, 
may be used. As the parts begin to contract by the advanced 
healing of the ulceration, the closure, partial or entire, should be 
anticipated by the introduction, daily or oftener, of wax, rubber, 
or other sort of bougies. It is well, when this last expedient is 
necessary, to smear them with ointment that may exert a healing 
influence on the ulceration. The physician cannot be too atten- 
tive to these cases. He should see to it personally that his direc- 
tions are carried out, and feel himself responsible for any serious 
permanent injury that can result from want of diligence. Women 
or their nurses cannot understand, and it is feared physicians do 
not properly appreciate, these means of averting the awful acci- 
dents which result from the sloughing and ulceration in these 
cases. 

Vaginismus. — Dr. Sims described this affection first to the Ob- 
stetrical Society of London, December, 1861, and has since given 
it to us in his "Clinical Notes on Uterine Surgery." It is an 
" hyperesthesia of the vulva and hymen attended with involun- 
tary contraction of the sphincter vagina." The parts are so very 
sensitive that the slightest touch with the finger causes great pain, 
and, in some instances, coition is entirely impracticable. In all 
the cases I have ever examined, there was very decided redness 
and increase of the secretion of the parts exposed by separating 
the labia. Dr. Sims thinks that the sensitiveness is confined to 
the vulva and hymen, but I apprehend that more extended obser- 
vation will convince him that the whole vagina is involved. In 
one of my cases now under treatment, the sensitiveness of the 
vulva has almost entirely disappeared; the finger may be intro- 
duced into the vagina, but the upper part of this cavity is so ex- 



VAGINISMUS. 55 

quisitely tender that the patient screams with pain as it approaches 
the cervix uteri. 

The general symptoms are grave according to the chronicity of 
the case. It generally shatters the constitutional energies of the 
patient, rendering her a wreck, according to the expression of Dr. 
Sims. Dr. Sims says it is independent of inflammation. Mr. I. 
B. Brown agrees with him. It is according to them mere hyper- 
esthesia. In my cases the parts were always in a state of in- 
flammation; hut I cannot think the hyperesthesia was wholly of 
inflammatory origin. Of course I am not prepared to say that in- 
flammation is even a general attendant. The observation of the 
profession will soon determine that point, as the disease is now 
fairly set before it, and, from its distressing symptoms, will attract 
much attention. My patients have all been barren, and were ap- 
parently not aware of their condition until married. The inten- 
sity is not always sufficient to prevent coition, and sometimes is. 
much greater than others. The sensitiveness is greater near the 
menstrual epoch, occasionally in a very marked degree. 

Diagnosis. — The sensitiveness is characteristic, and hence there 
is no need of much labor in forming a diagnosis. The least touch 
of mucous membrane of the vulva, with a feather, soft brush, or 
fingers, gives the patient great suffering, and sometimes agony un- 
like anything else. 

Prognosis. — Judging from all I have seen and read upon the 
subject, there is very little, if any, tendency to spontaneous subsi- 
dence. Its duration, therefore, is perplexingly long. But all agree 
as to its curability. 

Treatment. — Dr. Sims has succeeded in curing all his cases by 
dividing the sphincter vagina deeply on either side of the vaginal 
orifice. He makes the division sufficiently deep to permit of free 
dilatation, and then keeps the vagina open with large bougies un- 
til the wound cicatrizes. The results of this operation are all that 
might be expected from it. The hyperesthesia disappears, and 
the obstacles to coition are removed, but there is necessarily great 

mutilation. Mr. I. Baker Brown, in his Surgical Diseases of re- 
's 

males, condemns this procedure as severe and needless, and gives 
two cases where the sensitiveness was cured by the relief of fissure 
of the rectum. He thinks the hyperesthesia is a symptom of 
some disease of the rectum, generally fissure ; and that by inci- 



56 VAGINISMUS. 

sion of the fissures it will disappear. Dr. Braun, of Vienna, ac- 
cording to Mr. Brown, has cured one case by removing the clit- 
oris. A case of some severity is reported in the London Lancet, 
American reprint for March, 1867, in the care of Dr. G. C. P. 
Murray, in which the hyperesthesia appeared to depend upon in- 
flammation of the cervix uteri and vagina. It was cured by 
making a free application of the solid nitrate of silver over the 
inflamed cervix, and a solution to the vaginal surface. These ap- 
plications were repeated in a fortnight, and were succeeded by the 
tinct. iodine. While there can be no doubt that Dr. Sims's plan 
is efficacious, I cannot think it necessary, and the success of other 
means by different practitioners, bears me out in this opinion. 
We almost always find the patients in a state of health unsatis- 
factory, and, according to my observation, evident local disease 
besides that of sensitiveness ; and, from what we have learned 
from Mr. Brown and Dr. Murray, more than one kind of local 
disease. As in the treatment of all other diseases, therefore, we 
should carefully and diligently search for the cause of the hyper- 
esthesia. If it is fissure of the rectum, this should receive our 
first attention ; if inflammation of the vagina, uterus, or vulva, we 
ought to cure this. 

In all the cases I have seen, and I now have three under treat- 
ment, nothing I have tried has been of so much advantage as reme- 
dies directed against inflammation of the vagina and vulva. The 
course I usually pursue, is to apply the solid nitrate of silver to 
the vulva every ten or fourteen clays, and in the interval use gly- 
cerine and tannin. The first application reduces the sensitiveness 
very decidedly, and it becomes less after each successive touch, 
until finally cured. We should bear in mind that the hyperes- 
thesia does extend into the vagina and near to the uterus, and 
that there is equal necessity to treat the vaginal cavity as the 
vulva. I have been in the habit, in fact, of managing it as I would 
vaginitis. The strong astringents, glycerine and narcotics, ap- 
plied by means of medicated pessaries and injections, are valuable 
adjuncts. With the local treatment, rational general treatment 
is very beneficial. Attention to the bowels, the condition of the 
stomach, and the secretions generally ; tonics, exercise, change of 
air, bathing, attention to clothing, and all the regimenal circum- 
stances calculated to benefit the general condition of the patient. 



VESICO-VAGINAL FISTULA. 57 

Vesico-vaginal Fistula. — Although generally resulting from puer- 
peral vaginitis, it is sometimes produced by other causes. Exten- 
sive ulcerations from pessaries sometimes penetrate the septum 
between the vagina and bladder. Stone or other foreign bodies in 
the bladder may act as causes of ulcerative processes of sufficient 
gravity, to do the same. Malignant diseases, as cancer of the 
uterus, vagina, or bladder, not unfrequently lay open these cavi- 
ties. And, in some rare instances, perforations by the unskilful 
use of instruments have been observed. 

The fistula, when established, is oftener than otherwise associated 
with other effects of the disease from which it is produced. Cica- 
trices and contractions of the vaginal walls are very common ac- 
companiments. These embarrass examinations and operations 
very much when extensive. They also change the size, shape, 
and direction of the vaginal cavity. Fistulse of the bladder are 
located near the urethra, involving this tube ; at the cervix uteri, 
involving that organ ; and again, in the middle, between these two 
points. But these fistulse are also occasionally urethro-vaginal or 
vesico-uterine, without affecting any other parts. Their size va- 
ries from a mere pin-hole to several inches in diameter. They are 
situated lengthwise, crosswise, or diagonally, with reference to the 
direction of the vagina. 

The constant flow of urine through the vagina, instead of the 
urethra, is a sufficient symptom to decide the existence of fistula, 
but we meet with cases where the flow of urine is not constant ; 
the patient being able to retain for some time, and then discharge 
her urine naturally. This circumstance is due to the plugging of 
a small opening by mucus, or the prolapse of some part of the blad- 
der into the fistula. In all instances it is proper and necessary 
to make a clear diagnosis of its existence, size, shape, position, and 
complications. This is done by the fingers and probe. The pa- 
tient should lie on her back with the hips near the edge of the bed, 
and her 'legs flexed so that we may have free use of both hands. 
The fingers will readily pass through a large fistula into the bladder, 
and, by moderate care, be made to thoroughly survey it and the 
surrounding parts. But the fistula may be so small, or situated 
so as to entirely escape detection by the finger. We will be aided 
in such cases by introducing a probe, slightly bent, through the 
urethra with one hand, while the fingers of the other are in the 



58 VESICOVAGINAL FISTULA. 

vagina. The bent extremity of the probe is turned toward the 
septum, pressed gently upon and passed over every part of it, un- 
til it is made to pass through the opening, when it may be recog- 
nized by the finger in the vagina. Having found the fistula, as- 
certained its size, position, shape, direction, &c, we ought to sur- 
vey the vagina, to find strictures or other deformity, and ascer- 
tain the distensibility of this tube. We do this in part to deter- 
mine the prognosis of the case. Can the fistula be cured ? is a 
pertinent and important question, which will be decided by this 
kind of examination. Fortunately, now, thanks to Dr. Sims, al- 
most anything short of loss of the whole septum may be cured. 
If the fistula consists of a defined opening, it matters little how 
large, we are justified in expecting success. If, as is sometimes 
the case, there are no sides, edges, or ends to it, but the vagina 
and bladder are one cavity, smooth and continuous, we cannot 
reasonably undertake an operation, unless it be to close the vulva, 
as has been suggested, if not practised, by Dr. Sims. Some cir- 
cumstances, independent of the character and size of the fistula, 
are necessary to insure success. The vagina should be healthy. 
If the walls of this cavity are in a state of inflammation or conges- 
tion, the prospects of a cure are more remote. Great nervous sus- 
ceptibility is sometimes difficult to overcome, and should be a rea- 
son to defer the operation. 

The general health of the patient is also a matter of the first 
importance. A highly nervous condition of the system, with an 
abundance of lithates in the urine, is a condition in which there 
are many chances for failure. Some surgeons lay stress upon a 
preparatory process, for a number of days, or even weeks, to avoid 
an aplastic condition. They administer the tincture of iron, wine, 
and nourishing diet, to render the diathesis plastic, or favorable to 
adhesive inflammation. The patient should be in the best possible 
health, and if she is not, whatever is the deviation, it is best to 
take time to correct it. In many instances, as before remarked, 
the inflammation which causes the fistula also produces cicatrices, 
that narrow, distort, or tie down the vaginal walls. These diffi- 
culties should be corrected before we undertake to operate. The 
strictures should be divided, and the vagina kept dilated until its 
normal condition is restored as nearly as possible. After the ef- 



VESICO-VAGINAL FISTULA. 



59 



fects of these preparatory operations are over, we may consider 
the patient ready for the main operation. • 

The only other step will be the administration of a cathartic to 
evacuate the bowels. The ca- 



Fia:. 2. 



Pier. 4 



tharsis ought to be entirely over 
at least twelve hours before the 
operation. With these prelimi- 
naries accomplished, we should 
have a large window on the 
sunny side of the house, a sun- 
shining day, four assistants, a 
table of convenient height, five 
feet long, and two wide, and the 
necessary instruments. The ta- 
ble, covered with one or two 
quilts, is to be placed with the 
end toward the window, from 
four to six feet distant. The pa- 
tient lies on her left side, the 
limbs drawn up, the right rather 
most, with the left arm behind 
her, so that she rests full on the 
front of the chest. One of the 
four assistants uses the chlo- 
roform, another the speculum, 
a third the sponges, and the 
fourth attends to the instru- 
ments. On a tray within easy 
reach of the operator, the in- 
struments should be placed. 
They are the speculum, tenacu- 
lum, scissors, two long sponge-holders, forceps for carrying the 
needles, one wire adjuster, blunt hook, forceps to twist the wire, 
half a dozen needles, slightly curved, about one inch long, armed 
with small silver wires about twelve inches long, an elastic male 
catheter, or one of Sims's S-shaped instruments, with an India-rub- 
ber tube, a little larger than the catheter, to carry the urine clear 
of the bed. The surgeon takes his seat at the end of the table 
next the window, near the breech of the patient, introduces the 




Fig. 2, tenaculum, with which to hold the edge 
of fistula while being pared; 3. curved scissors, 
for paring edge of fistula ; 4, wire adjuster. 



60 



VESICOVAGINAL FISTULA. 



speculum, dilates the vagina, and thus brings the parts thoroughly 
in view, and then gives the instrument to the assistant to keep in 
Fig. 5. 




Fig. 



Fig. 6. 



Fiff. 8. 



that position. If 
there is anything in 
the position of the 
patient that pre- 
vents the parts from 
being thoroughly 
exposed and light- 
ed, it should be 
changed until this 
is the case, when 
the operator may 
proceed as follows : 
With the tenaculum 
in the left hand, the 
edge of the fistula, 
in the most remote 
angle of. the open- 
ing, is transfixed 
and held up to view, 
and, with the scis- 
sors, bevelled from 
the mucous mem- 
brane of the bladder 
outward. As much 
should be removed 
in this way, with- 
out changing the 




Fig. 5, speculum for dilating vagina; 6, forceps 
for twisting the wires; 7, the catheter; 8, needle 
forceps; 9, sponge holder. The instruments are 
represented half size. 



VESICOVAGINAL FISTULA. 61 

place of the tenaculum, as practicable. Another place on the 
edge of the fistula is seized, and trimmed in the same manner, and 
so on, until the whole circle is denuded completely of the cicatri- 
cial tissue. As this part of the operation is being accomplished, 
the assistance of the sponge will be called into use on account of 
the bleeding. I do not see the necessity of removing as much 
substance from the edge of the fistula as is directed by some 
authors. The main object, I think, is to have the edges evenly 
and thoroughly denuded of the mucous membrane. This much 
should be done with a completeness that admits of no doubt, and 
if we have a good light, there need be no doubt, as we can see and 
examine the part sufficiently well to be positive. After the bleed- 
ing has ceased, we may insert the sutures. We commence at the 
angle of the wound most remote and difficult to reach. The needle 
is to be introduced first into the lip of the wound nearest to the 
operator, by starting it in about half an inch from the freshened 
edge, dipping it down, so as to make the point come out in the 
denuded portion, just at the junction of it and the vesical mucous 
membrane. The needle being brought through at this point, is 
again inserted in the opposite edge, corresponding as nearly as 
possible with that part whence it emerged, and carried forward far 
enough to emerge half an inch beyond the edge of the wound, and 
drawn through. The ends of the wire thus fixed are held by the 
assistant engaged with the speculum. The next suture is to cor- 
respond with and be placed within two lines of the first. They 
are thus placed in sufficient numbers to close the opening com- 
pletely. (See Figure 10.) Having all the sutures introduced, 
the one nearest the operator must be isolated and twisted by the 
forceps made for that purpose, until the angle of the wound is 
evenly coapted. The next, and so on of the remainder, is to be 
managed in the same way. Great care must be taken to see, 
as the closure is effected, that the lips of the wound are drawn 
evenly and smoothly together. (See Figure 11.) If we are not 
particular, the edge of one side or the other rolls slightly in, and 
unfreshened mucous membrane is brought up to denuded surface. 
This, I think, is a circumstance that is very liable to occur in 
the hands of an inexperienced operator. Both the insertion of the 
sutures and bringing together the edges may be facilitated by the 
skilful use of the tenaculum and the adjuster. The tenaculum 



62 



VESICO-VAGINAL FISTULA. 



will enable us to disengage and straighten the edges, in adjusting 
them, and in inserting the needles keep them firm. The adjuster 
will place the twist of the wire in any position with reference to 

Fig. 10. 




The fistula with edge pared and the sutures placed. 



the junction of the wound we may desire. In twisting the wire 
there are two things to be avoided, — one is tightening it too much, 
and the other leaving it too lax. Experience will fix these items 
after a few operations, but I think that the operator may venture 
to tighten the twist of the wire until it fixes but does not strangulate 
the part included in the stitch. After the twist is completed, we 
ought to be able to pass an ordinary probe through the circle of 
the stitch without much force, and yet, upon its removal, there 
should be no apparent space. If the stitch is drawn too tightly, 
the parts will be strangulated and cut through early by ulcera- 
tion ; if too loose, the urine will pass through as the bladder 



VESICOVAGINAL FISTULA. 



63 



becomes filled, and prevent adhesion. The last thing in the oper- 
ation is to cut the wires about half an inch from their insertion, 
and bend them down in the direction of the wound, leaving the 
ends lying centrally upon it. The operation finished, the catheter 
may be inserted, the patient place'd carefully in bed, on either 
side, and a grain of opium administered. The catheter will some- 
times become foul with deposits, and require cleaning every twelve 




Closing the wounds and twisting the wire sutures. 



or eighteen hours, but as a rule, while the urine is running freely, 
it may remain in place. Great watchfulness will alone prevent this 
instrument from being misplaced. The great desiderata of the after- 
treatment, are to prevent an accumulation of urine in the bladder, 
and the bowels from being evacuated. The former can be cer- 
tainly accomplished in no other way than by having a competent 
assistant by the patient, or very near her all the time, and when 
the catheter does not deliver the water freely, to have it removed 
and replaced by a clean one, however frequently that may be 
required. We may keep the bowels quiet by administering a 
grain pf opium twice or three times a day. If the patient is very 
restless, we ought to give as much more as is necessary to quiet 



64 



RECTO-VAGINAL FISTULA. 



Fig. 12. 




Removing the sutures. 



this. The only other important item of treatment, as a general 
thing, is cleanliness, and for this purpose, vaginal injections of 
tepid water with fine toilet soap, twice or three times a day, will 
suffice. The vagina will thus be kept clean with much certainty. 

The diet should not be too sparing. 
The ordinary diet of the patient, in 
half or two-thirds of the quantity, I 
am convinced is better than any con- 
siderable change in quality. The 
patient must remain quiet as practi- 
cable for nine or ten days, when, 
prior to taking out the sutures, we 
should try the capacity of the blad- 
der, by leaving the catheter out for 
an hour, and then drawing off the 
urine. There will be no good in 
leaving the sutures in place longer 
than ten days, perhaps, but there 
can be no harm result from their 
presence longer. The removal of 
them is easily accomplished, by passing one blade of the scissors 
within the circle of the stitch, and dividing it, when the wire may 
be withdrawn by the forceps. For the first three or four days 
the patient should wear the catheter at night, and pass her urine 
every two hours in the day, gradually lengthening out the time. 

I have given this description of operation, because it is the one 
most nearly approaching, if not identical, with that now performed 
by Dr. Sims, after all his great experience, — a sufficient commenda- 
tion without any other, — the simplest and easiest of comprehension 
and performance, as well as. in my humble judgment, most uni- 
formly successful. Dr. Sims does not now use chloroform in this 
operation, but I have been obliged to resort to it in most of my 
cases. When a patient can be induced to do without it, we will 
get along better than if she is anaesthetized. 

Recto-vaginal Fistula. — This accident does not so frequently 
as vesico-vaginal fistula result from puerperal vaginitis. Stric- 
ture of the rectum, abscess of the recto-vaginal septum, rupturing 
into both cavities, and accidents with instruments, as often cause 
it, perhaps. It is not so common or frequent as vesico-vaginal 



RECTO-VAGINAL FISTULA. 65 

fistula, nor so distressing. The passage of the faeces, if proper 
cleanliness is observed, although disgusting, is not so productive of 
inflammation and excoriation as urine, and their discharge may be 
controlled by appropriate fixtures. A cure is also more easily ac- 
complished ; indeed, it is often spontaneous. As the contents of 
the bowels pass intermittingly, and, when in contact with the raw 
surface, do not irritate it considerably, the ulcer has time to con- 
tract, and healthy granulations, in a good state of the general 
health, is the result. 

The symptoms and diagnosis of this fistula are so obvious, that 
I need not dwell upon them ; but we sometimes meet with cases 
where the opening is so Small and tortuous, that great patience in 
the use of the probe will be required to satisfy ourselves as to its 
position and direction. The injection of water into the rectum 
while the parts are under inspection will generally clear up all 
doubts. 

Treatment. — If we are associated with these cases during the 
ulcerative condition, we may conduct them to a cure with great 
certainty, and, perhaps, more readily than after the edges of the 
opening have cicatrized. The important items of treatment at 
such times are, 1st. Proper attention to the bowels ; 2d. Great 
cleanliness ; and, 3d. Maintenance of healthy granulations until 
the contraction obliterates the opening. The bowels should be 
kept quiet as much of the time as possible. To accomplish this, 
the diet should be concentrated and nourishing in character ; beef 
essence, milk, eggs, crackers, coffee or tea, and, if necessary on 
account of debility, wine, or medicinal tonics; and if the bowels 
have a tendency to move, opium in such quantities as will restrain 
them. Every four or five days a gentle alterative, say three grains 
of massa hyd., followed by a saline cathartic ; after the bowels 
have moved from this, the opium may be given to restrain them 
for four or five days again, and so on until the opening is closed. 
During this treatment, there should be frequent injections in the 
vagina of water. The part should be examined with the speculum 
every day, to see that the edges remain raw. When there is any 
tendency to cicatrize, the edges may be freely touched with pure 
nitric acid. If the cure is protracted, the acid should give place 
to the actual cautery. Toward the last, as the opening becomes 
small, especially if it is tortuous, a piece of twine, or what is, per- 

5 



RECTO-VAGINAL FISTULA. 



haps, better, a silver or iron wire, may be passed through it, and 
the ends "brought out through the anus and vagina. If the ease is 
chronic, and the opening small, the application of the acid may be 
made every day until the edges are denuded, and then the same 
course followed as above directed. Of course, these applications 
must be made through the vagina with a speculum that completely 
exposes the part touched, If the place is large and chronic, we 
will very much shorten the process of cure by an operation similar 
to that for vesico-vaginal fistula. After having thoroughly evacu- 
ated the bowels, the patient may be placed in the lithotomy posi- 
tion, and exposing the parts to a strong light, the perineum may 
be retracted by the rectangular speculum blade of Sims, while 
the vulva is held open by assistants. The edges are then to be 
pared thoroughly, and the aperture closed with silver sutures. 
The bowels will require the use of from two to four grains of opium 
daily to keep them quiet. They should not be allowed to move 
for ten days, when a saline cathartic should be given, and after it 
has operated well, the stitches removed. During the time between 
the operation and the removal of the stitches, the patient is to re- 
main quiet in bed, and have injections, per vaginam, of tepid water 
with soap, twice a day. If by this operation there is imperfect 
closure of any part, the treatment recommended for recent cases 
will suffice to complete the cure. Even these larger sized fistulse 
are sometimes cured by the caustic acids, the actual cautery, or 
tinct. litta ; but it takes a longer time, and is attended with more 
pain and annoyance. The operations on these fistulse will be 
greatly facilitated by having the breech of the patient projecting 
somewhat over the end of the table. 



CHAPTER V. 

MENSTKTJATION A1STD ITS DISOKDEKS. 

Several conditions are necesssary to the healthy performance 
of the functions of menstruation. 

1st. The ovaria must be present, and sufficiently healthy to 
produce ova. 

2dly. The uterus must be sufficiently perfect, anatomically and 
physiologically, to be the medium of this elimination. 

3dly. A certain, but not as yet very well-defined, state of the 
blood and nervous system. 

I do not think that these are all the conditions necessary to 
perfect menstruation ; but they are the obvious and undoubted 
ones. 

The physiological 'chain of circumstances that give rise to men- 
struation may be given thus : the organs concerned being fully 
developed, the blood and nervous system matured to a certain 
degree, an ovum is produced, and during the time it is being ma- 
tured and cast off from the ovary, all the organs of generation are 
intensely congested by the increased energy of the capillary cir- 
culation ; the congestion and stress of blood upon the delicate cap- 
illaries of the mucous membrane of the uterus become so great, 
that the walls of some of these vessels are ruptured, and an effu- 
sion of blood takes place in the cavity of the uterus, which, find- 
ing its way out of the vagina, is called menstruation. If ovula- 
tion does not take place, the congestion does not occur, and in the 
absence of the congestion there is no effusion. All these processes 
which accompany menstruation should be painless, and only of a 
certain grade of activity to be healthy. When absent, deficient, 
painful, or in excess, the function is deranged. 

This very brief summary of the general physiological principles 
of healthy menstruation, will do for a starting-point, in the consid- 
eration of the disorders of them. And as I proceed, I shall have 
occasion to mention pathological states, which are superadded to 



DO • MENSTRUATION AND ITS DISORDERS. 

a deviation from the above conditions, as also some that induce de- 
rangements of menstruation, notwithstanding the presence of them 
in a healthy degree. 

I shall consider the disorders of menstruation under four differ- 
ent divisions : 

1st. Amenorrhosa. 

2dly. Menorrhagia. 

3dly. Dysmenorrhea. 

4thly. Misplaced menstruation (Metatithmenia). 

Under these four heads may be included all the deviations met 
with in ordinary practice. It is usual with authors to make only 
three distinct divisions. My fourth division is spoken of by those 
who have described it as uterine hematocele, hematoma, &c. ; but 
I shall give what I consider good reasons for classing it under the 
general head of menstrual disorders. 

Amenorrhea. — Amenorrhcea simply means the absence of men- 
struation, and may appear under several different circumstances. 

1st. Menstruation may never make its appearance in the indi- 
vidual. 2dly. After having occurred it may cease, or, as the term 
is, be "suppressed;" and this suppression again may be suddenly 
brought about, and attended with acute symptoms, and hence prop- 
erly denominated acute suppression ; or it may not be attended 
with acute symptoms, and last long enough to be called chronic. 
3dly. I should think it right to consider deficient menstruation as 
suppression, although but partial. This partial suppression as- 
sumes two forms, viz., infrequency, when the intervals are uncom- 
monly long ; and scantiness, the return being regular, but the 
quantity of the discharge much less than it should be. Or there 
may be both scantiness and infrequency. 4thly. The menses may 
be retained in the cavities of the uterus or vagina, or both, after 
having been effused. This retention is very different in many re- 
spects from the suppression ; giving rise to quite a different set of 
symptoms, and requiring a separate sort of treatment, agreeing 
with it only in the non-appearance of the blood externally. 

The pathological states upon which the symptom amenorrhoea 
is based are very numerous, and sometimes inscrutable. The more 
obvious are the following: congenital absence of the uterus or 
ovaria, or both ; congenital non-development, or acquired atrophy 
of these organs ; disease of the uterus and ovaria, acute or chronic. 



AMENORRHEA. 69 

These are the ordinary local causing conditions. The general are, 
anaemia, cachexia (as tuberculous, scrofulous, &c), pregnancy, and 
nursing. Serious diseases of any of the vital organs may, under 
certain circumstances, give rise to amenorrhoea. 

The local symptoms which attend the absence of the menses will 
differ according to the conditions which give rise to it. In acute 
amenorrhoea, we shall have signs of great congestion, or inflamma- 
tion of the uterus. The patient, after commencing to menstruate, 
being subjected to the causes necessary to suppression, such as the 
partial or general application of cold, is seized with pain in the 
back, hypogastric region, and hips, attended with a sense of chil- 
liness more or less intense. These symptoms are usually succeeded 
by febrile reaction, headache, pain in the limbs, general languor, 
white tongue, and a persistent pain of varied severity in the region 
of the uterus. There is, in this state of things, as there seems to 
be, inflammation of the uterus. The symptoms may subside, and 
generally do in a very few days, leaving more or less local discom- 
fort in the pelvis and neighborhood. At the next menstrual period, 
if the uterus is not much inflamed, and the system not greatly de- 
ranged, the blood is effused, but seldom with the same naturalness 
in quantity, quality, and painlessness, as before ; but there is more 
or less pain, which is again manifested henceforth at each succes- 
sive period. 

At other times the discharge fails to show itself after having 
been thus suppressed, and the case becomes chronic, and lasts an 
uncertain length of time. When this is the case, the non-appear- 
ance is likely to be attended by chronic inflammation of the uterus, 
or ovaria, as the result of the acute attack ; or the morbid effects 
brought about by uterine sympathies derange the stomach, bowels, 
liver, in fact, all the chylopoietic organs, to such a degree, as to 
render chymification or chylification imperfect. Sanguification will 
be thus vitiated, anaemia or cachexia results, and the patient is 
broken down and " miserable;" or we may have a combination 
of these two states and the symptoms to which they give rise. I 
cannot but see in this catenation of circumstances, the complicated 
effects resulting from inflammation of the uterus. Should the 
amenorrhoea be primary, — by this I mean to say, should the 
menses never have made their appearance, — the girl, if old enough 
and sufficiently developed, will suffer differently. And there is 



70 MENSTRUATION AND ITS DISORDERS. 

very nearly, if not quite, the same set of symptoms present in cases 
where they have made their appearance imperfectly, in quantity 
and quality, or for a few times, and then ceased. The patient 
suffers under the symptoms of imperfect sanguification : inability 
to exercise, palpitation of the heart, shortness of breath, torpid 
liver and bowels, want of apppetite, or depraved appetite ; desiring 
improper food at improper times, despondency, great apathy, and 
timidity. The surface is pale, and either white and translucent, 
or, what is much more common, of a greenish hue. This condition 
of the system was formerly styled chlorosis. The sufferings are 
often very great and protracted, and not unfrequently merge into 
those of tuberculosis, insanity, or other serious organic diseases. 
It is not unusual, even in cases where menstruation has never been 
perfectly established, to find the patient afflicted, also, with symp- 
toms of inflammation of the uterus. 

The general symptoms accompanying scanty menstruation, 
when the scantiness is the result of imperfect establishment, are 
very much of the above character, viz., those connected with an- 
aemia, &c. But, as is frequently the case, the scantiness and infre- 
quency, as also the entire suppression of menstruation, depend 
upon organic changes in the uterus gradually brought about by 
chronic inflammation. What these are we cannot always deter- 
mine. Sometimes, however, we find the fibrous structure con- 
densed until the bulk of the organ is smaller and harder than 
natural ; at other times it is greatly enlarged, as I have verified 
by examination. The most common, I think, is condensation and 
atrophy. In such instances, there will, of course, be quite a dif- 
ferent set of symptoms, in fact, many, if not all, the symptoms 
found described in connection with chronic inflammation of the sub- 
stance of the cervix and body of the uterus. I need not enumer- 
ate them here, but refer the reader to the article in which the 
general symptoms of these conditions are given. Chronic amenor- 
rhoea, scanty or infrequent menstruation, are in this way asso- 
ciated with the most miserable states of the general health. I do 
not believe, however, that the mere absence of the menses is the 
cause of such terrible nervous suffering as we often see associated 
with it, but that much of it is caused by the condition of the ute- 
rus and other organs upon which the irregularity depends. The 
non-appearance of the menses on account of the absence of the 



AMENORRHEA. 71 

uterus, is not usually attended with the chronic suffering I have 
here alluded to, ordinarily, and indeed in all the cases — which 
are three — of this kind to which my attention has been called, the 
patients appeared to be perfectly well. One of these patients was 
thirty-three years of age, another twenty-seven, and the third 
twenty-two, and although they all ought to have menstruated 
several years before I saw them, they were in perfectly good 
health. This is an argument, I think, in favor of the opinion 
just expressed, that the serious and annoying symptoms arise from 
the pathological condition of the uterus, or general conditions 
giving rise to it. The only symptoms these patients complained 
of at any time that seemed to be attributable to amenorrhoea, were 
the backache, weight about the hips, &c, which denote the pres- 
ence of the menstrual molimen in well-formed persons. In the 
cases where ainenorrhoea exists before the organs are sufficiently 
developed to assume the function of menstruation, we often observe 
a good state of health, even after the person has attained to an age 
when they are expected. I have had occasion to see, examine, 
and watch for several years, two cases of chronic amenorrhoea from 
deficient development of the uterus and, perhaps, ovaria. They 
were both married. One of them is twenty-eight years of age, 
has been married nine years, has never menstruated, has no sexual 
desires, but lives happily with her husband, and desires to be like 
other women merely to have a child for him. There are no dis- 
tressing symptoms in her case. Her breasts and uterus are 
developed to about the size of a little girl of thirteen years of 
age. There is hair upon the pubes, the mons is well developed, 
as is also the clitoris. The other has been married three years, is 
twenty-five years old, and resembles the first completely. 

Tuberculosis when causing amenorrhoea is usually w r ell mani- 
fested before the suppression occurs, but sometimes this symptom 
shows itself so early in the case that it is regarded as the cause of 
the consumption instead of the effect. 

From what is said above, the reader will see that amenorrhoea 
is a symptom of the absence, imperfection, or disease of some of 
the organs of generation, or some grave deterioration of the blood 
or nervous energies, and that we are to look into all the circum- 
stances which attend upon it, with a view to learn the causing con- 
ditions. We are not always fortunate enough to be able to do 



72 MENSTRUATION AND ITS DISORDERS. 

this, and we will then be under the necessity of contenting our- 
selves with conjecture, and the necessary uncertainty of treatment 
we adopt. 

Retention of the menses, as I have remarked, is quite a differ- 
ent thing from a suppression of them. It is always the result of 
congenital or acquired occlusion of the genital canal. The os or 
cervix uteri or the vagina may be occluded as a malformation. 
The ostium vagina may be occluded by a hymen, in such way as 
to entirely prevent the discharge of the menses. Adhesions oc- 
curring in infancy, childhood, or adult age, may give rise to the 
same occlusion. The most common cause of adhesion is inflamma- 
tion, from accidents or negligence in childbearing, or want of 
cleanliness in childhood. 

After the menses have been retained for a few months in the 
vagina or uterus, the abdomen begins to swell more or less rapidly, 
according to the quantity produced each month, until the distended 
uterus may be felt above the symphysis, rising higher each month. 

The distress in these cases seems to be caused by distension, and 
not from any other cause. There is weight about the loins, on 
the perineum, and finally, a sense of disagreeable tightness in the 
abdomen. We should always be suspicious of the existence of ob- 
structions to the flow of the blood when the amenorrhoea is com- 
plete, with but slight constitutional symptoms, and has withstood 
judicious treatment for a length of time. 

Diagnosis. — It is not usually difficult to determine positively 
when there is amenorrhoea, and yet, sometimes, there may be good 
reason to doubt in some instances. It is not necessary that there 
should be an effusion of blood to constitute menstruation, for there 
are periodical discharges from the genitals which indicate the pro- 
cess of ovulation, and, under certain conditions of the system, are 
more appropriate than an effusion of blood. I allude to a periodi- 
cal discharge of mucus or sero-mucus. The uterine congestion is 
not sufficient in quantity or force to give rise to hemorrhage, but 
to cause effusion of the thinner portions of that fluid. The point 
of diagnosis in which we are most interested, is to definitely ascer- 
tain the causing condition. We are often obliged to treat patients 
for a time without having more than their statements as a basis 
of our diagnosis, and fortunately, in most cases, this is sufficient. 
We are not justified, however, in continuing the care of an obsti- 



AMENORRHEA. 73 

nate case for any great length of time without making an effort to 
verify or ascertain the fallacy of the grounds for our opinion. 
And, if need be, we must resort to physical examination. The 
fact of our patient being a virgin should cause deference, but not 
forbid an examination indispensable to a correct understanding of 
the cause of a condition that is destroying her life. I need only 
mention that suppression attended with acute inflammation of the 
uterus and ovaries, will be attended with marked and almost in- 
variably unmistakable symptoms. The pain, fever, tenderness, 
and sympathetic symptoms will leave no room for doubt. Anaemia, 
cachexia, nursing, &c, are obvious conditions, and will be easily 
made out by very little attention. 

It should be borne in mind, in this connection, that we cannot 
always determine the causing condition of amenorrhoea, and after 
most ingenious and searching investigation, we are unable to do 
more than conjecture why the patient does not menstruate. Cor- 
rectness in diagnosis may be attained with great certainty when 
there is physical defect in the genital organs, by proper direct ex- 
aminations of them, and they should be instituted when other 
means fail to satisfy us. The presence or absence of the uterus, 
in most instances, can be pretty satisfactorily determined by intro- 
ducing the finger into the rectum and a catheter into the bladder, 
and approximating them. If it is present, its thickness interposed 
between the two will prevent the finger from defining the shape of 
the instrument ; if it is absent, they may be made to touch with 
the intervention of the walls of the rectum and bladder. The 
catheter, in this examination, should be introduced deep into the 
bladder, and the finger as far up the rectum as possible. With 
this precaution, there can hardly be a mistake. I have met with 
three instances of congenital absence of the uterus, and in all the 
vaginae were absent, but they presented all the external evidence 
of womanhood, such as perfect mammae, mons veneris, labia ma- 
jora, clitoris, and hair. The patients had the demeanor of women, 
and assured me that their desire for the society of men was as 
great as usual, and that they experienced strong sexual feeling. 
One of them had married, and was defending herself in a suit for 
divorce, upon the ground of her entire ignorance of any anatomi- 
cal defect in organization ; and the other was about twenty-two 
years of age, and submitted to an examination with the hope of 



7-4: MENSTRUATION AND ITS DISORDERS. 

having a correction of the physical defect, preparatory to enter- 
ing matrimony. It is possible that the vagina may be absent 
while the uterus is perfect in formation, — the same examination 
will furnish us with proof, — or the vagina may be occluded from 
defect of formation. This can be determined in the manner I 
shall presently describe. Absence of ovaria can perhaps not be 
determined by physical examination, but there is always such a 
complete absence of the signs of womanhood that we cannot long 
hesitate. There are no prominent mammae, the manners peculiar 
to the sex, desire for society of males, and sexual propensity, are 
absent. There is no hair on the pudenda, and the whole external 
organs are not developed. The signs are the same at any age. 
The patient at mature age presents no more evidence of sexuality 
than the little girl. 

I have very recently met with an instance of congenital atrophy, 
apparently, of the uterus. The patient, although now twenty- eight 
years of age, has not menstruated, unless, as she doubtfully said, 
twice when about seventeen years of age, very scantily. She is 
rather above medium size, and possesses all the characteristic ap- 
pearances of womanhood. She has enjoyed fair health until the 
last twelve months. Eor the past year she has suffered from dis- 
tressing palpitation of the heart, which almost incapacitates her 
for business. She has been married nine years, during which time 
she has enjoyed sexual intercourse indifferently. She has no 
monthly pains, the signs of menstrual congestions, and nothing by 
which to know when to expect that function. Her mammae are 
developed to a degree about equal to that of a girl of thirteen or 
fourteen years. They are very small in circumference, the diame- 
ter being about two inches and a half, with a thickness at nipple 
of about three-quarters of an inch. The nipples are very small. The 
orifice to the vagina is small, the labia very thin and undeveloped, 
and very slightly formed mons veneris. The uterus could be felt 
to occupy its usual position, only rather higher up in the pelvis, 
but was very light and small. When the fingers were placed under 
it in the vagina, and it was pressed down from above, it gave the 
sensation of diminutiveness, apparently not exceeding half its natu- 
ral size. The ordinary uterine sound would not enter it more than 
half an inch. A probe, with an extremity about the twelfth of an 
inch in diameter, freely passed up one inch and a half. From all 



AMENORRHEA. 75 

this, it was plain that the uterus was in a state of atrophy; and I 
infer that the ovaria were so, from the absence of the nervous 
signs of menstruation. 

The size of the organs, as measured by the means and on the 
plan above indicated, determines, together with the history of the 
case, that it is congenital atrophy. Acquired atrophy is confined 
generally to the uterus, while congenital atrophy generally involves 
all the genital organs, including the breasts and nipples. 

I have met with a number of instances of acquired atrophy, and 
in carefully tracing their history, could attribute it to some early 
miscarriage, which it seemed to follow. And this atrophied con- 
dition, doubtless, was hyper-involution of the organ after abortion. 
I believe I know of no case that did not thus originate. In look- 
ing over the menstrual history of these sufferers, there was a time 
when they menstruated normally, and the function was disturbed 
after having been thus established; and upon making a physical 
examination, the uterus is found much smaller than it ought to be. 
When amenorrhcea is attended by chronic inflammation of the 
uterus, a not unfrequent occurrence, the speculum and probe will 
reveal the condition beyond the probability of making a mistake. 
I have seen the .worst forms of indigestion, and very great emacia- 
tion, attend this condition ; in fact, I have seen no other benign 
disease of the uterus produce so much emaciation as this. The 
patient is sometimes bedridden for months. In two instances re- 
cently cured by local treatment and proper dietetics and hygienic 
regulations, the patients were reduced to two-thirds their ordinary 
weight. 

Occlusion with retention may be diagnosed by the history of the 
case, tumidity of the uterus, protrusion of the distended part into the 
vagina or external to it, a fluctuating insensible tumor felt through 
the anterior walls of the rectum, by introducing the finger into 
that bowel and pressing forward. A thorough inspection will dis- 
close the point of occlusion. This condition is so obvious, that 
there is scarcely any likelihood of being mistaken, if we are at all 
careful and thorough. It is not always an easy matter to deter- 
mine the extent of these adhesions. I saw an instance of the 
effect of inflammation succeeding to a disastrous parturition, where 
the vaginal orifice was completely closed, commencing with the 
labia minora; I was unable to determine how far the adhesion ex- 



76 MENSTRUATION AND ITS DISORDERS. 

tended, but believe that the whole vaginal cavity was obliterated. 
This did not, at the time I examined the patient, make much dif- 
ference, as there was no distress from distension ; indeed, I could 
not find that the uterus was at all enlarged from distension, 
although it was two years after the inflammation had subsided 
that I saw the case. 

Prognosis. — The curability of amenorrhea will depend on the 
causing conditions. When occlusion of some portion of the geni- 
tal canal prevents the discharge of the menses, we can usually, by 
surgical means, evacuate it, and establish an outlet for the future. 
Although simple and easy of accomplishment, the evacuation of a 
long-retained and considerable accumulation is always attended 
with hazard. In the first place, inflammation may foil our efforts 
to establish a permanent viaduct for the blood which may be dis- 
charged from the uterine vessels ; and in the second, this process may 
be so great and extend to the peritoneum in sufficient intensity as 
to cause the death of the patient. Amenorrhoea from anaemia may 
be pretty surely cured ; in fact, it is the curable variety compared 
to those connected with other causing varieties. When arising 
from inflammation, it will also generally yield to appropriate treat- 
ment, as the cure wholly depends upon the removal of the causing 
conditions. The cachexia which may produce amenorrhoea is 
often entirely incurable, and, therefore, must our prognosis be un- 
favorable when they are associated. 

In all cases of absence of the ovaria or uterus, we could not ex- 
pect to do good by any treatment. Where there is only atrophy 
of the organs, we may hope that some of the ingenious contri- 
vances to increase their development which our profession of the 
present day affords (they have almost all emanated from, or been 
perfected by, the fertile genius of Prof. Simpson, of Edinburgh), 
may enable us to succeed. It cannot be concealed, however, that 
these causing conditions will often resist every means within our 
reach. To sum up, then, according to my observation, when amen- 
orrhoea arises from any other causing condition than general 
anaemia, or inflammation of the uterus or ovaria, the prognosis is 
not very promising, and we should be cautious in promising a per- 
manent and speedy cure. Failure in the function of menstruation 
is pretty sure to be accompanied with an inability for conception ; 
imperfection of it is, likewise, very frequently an evidence of bar- 



AMENORRHEA. 77 

renness. This is particularly the case with scantiness. When 
there is infrequent menstruation, but the function is otherwise 
perfect, the patient is often prolific. I have known a woman for 
several years, who does not menstruate more than three times in 
a year, and then not at regular intervals, and yet in the last six 
years she has had two children, conception following immediately 
after one of these irregular menstrual discharges. 

Treatment. — We should always bear in mind the fact that 
amenorrhoea is but a symptom, and endeavor to amend the condi- 
tion or disease upon which it depends. This rational mode of 
procedure, however, is not always practicable, for unfortunately, 
as has been more than once stated, we cannot in every instance 
ascertain precisely such condition. In such cases we make use of 
remedies, or plans of treatment, which, from the success that has 
occasionally followed their use, have gained the title of emraena- 
gogues. This term signifies promoter of menstruation. Are there 
any direct emmenagogues ? I think, in the nature of things, there 
cannot be. To cause a flow of the menses proper, which depends 
upon ovulation for its existence, they must produce or promote 
the evolution of ova. That there are remedies and plans of treat- 
ment which indirectly promote the menstrual discharge, I think 
there is very little doubt. In a general way, we ought to consider 
this class of remedies as producing their effects in two different 
modes : one is to cause the growth and discharge of ova, and the 
other the discharge of blood as a hemorrhage. It would be better 
then to say, that they were oviferous in their nature in the first 
case, and hemorrhagic in the second. To the first order belongs 
the preparations of iron and some other mineral and vegetable 
tonics, nutritious diet, exercise in the open air, diversion of mind, 
travel, sea-bathing, and, in fact, almost everything which is promo- 
tive of healthy functional action generally, by correcting the de- 
rangement of vital organs, and generating good blood and plenty 
of it. To the second, such as aloes, savin, cantharides, and any 
such hygienic measures, as foot, hip, and leg baths, sinapisms to 
the feet or legs, &c, such as determine blood to the pelvic organs. 

They may very properly be combined in some instances. I do 
not consider it necessary to go any farther in attempts to explain 
the modus operandi of remedies used for these purposes in this 
place ; they will come up in a different way as I proceed. I shall 



78 MENSTRUATION AND ITS DISORDERS. 

now take up the recognized, and, for the most part, palpable con- 
ditions presenting themselves for consideration as causes of amen- 
orrhoea. 

When amenorrhoea results from cold applied to the surface or 
lower extremities, or other cause suddenly acting to suppress the 
flow, the uterus and ovaria are bordering on if not in a state of 
acute inflammation, and the remedies for it should be directed to 
the relief of the diseased organ or organs. The question very 
naturally arises, can we, or ought we, to do anything to cause the 
return of the flow immediately upon its suppression ? and if so, 
what ? Experience teaches us that if the flow can be reproduced 
in a very few hours after its suppression, the turgid and phlogosed 
condition of the sexual apparatus may subside into a condition of 
health, and that this may sometimes be done by judiciously man- 
aged stimulation ; but if the flow is not re-established in a few 
hours, that we need not expect it to recur until the next period, 
if then, and that it is injudicious to continue stimulation beyond a 
very, short period. Then what is the proper course of stimula- 
tion ? If our attention is called to the case within twelve hours, 
and there is not much febrile reaction, we may very properly di- 
rect a hot bath to the whole person of the patient below the waist, 
for half an hour. The patient should then be put to bed, and two 
large mustard plasters placed upon the inner portion of the thighs 
and hypogastrium, and allowed to remain until a strong rubefacient 
effect is produced, when they may be removed, and the whole re- 
placed by a hot linseed-meal poultice. While these measures are 
being accomplished, we should administer copious draughts of 
some warm tea. I cannot approve of the gin-slings or toddies, 
given so freely under such circumstances ; they often do harm by 
their excessive stimulation, rendering the inflammation a fixed 
evil. 

Should the flux not return in twenty-four hours from the time 
of suppression, it would be unreasonable to expect and injudicious 
to continue treatment to cause it to do so. It then remains for us, 
if possible, to remove the phlogosed condition of the organs, so 
that they may be in a state to resume their functions at the return 
of the next ensuing menstrual period. 

It will be found, I think, that for the first month, in case of an 
acute suppression, especially in plethoric patients, the most sue- 



AMENORRHEA. 79 

cessful course of treatment will consist in a moderate antiphlogis- 
tic and alterative means, kept up steadily. The one I have ordi- 
narily followed is to use counter-irritatives to the hypogastric 
region, the hip-bath twice a day, of tepid water, six grains of blue 
mass every third night, to be followed in the morning by a seidlitz 
powder, and abstinence from all stimulants and highly seasoned 
food. If, however, the suppression continue beyond the second 
period after the suppression, it may be attended with chronic in- 
flammation, w T ith or without general anaemia, &c , and will come 
under some of the conditions hereafter to be considered. 

Ameuorrhoea connected with chronic inflammation of the uterus 
or ovaria may be treated as I have directed those affections to be 
managed elsewhere. I think that it is not very common for sup- 
pression, in the chronic form, to depend upon inflammation alone. 
More frequently the condition of these organs following inflam- 
mation, and sometimes remaining after its subsidence, are the 
causes of amenorrhoea, such as the condensation of the fibrous 
tissue without diminution in size, or the dense condition with 
atrophy. The same treatment, with little variation, is applicable 
to both. I shall have occasion to detail this treatment in speak- 
ing of atrophy and want of development. 

Another condition which succeeds inflammation of the uterus 
and ovaria, after an acute suppression, is anaemia. For there cer- 
tainly are cases in which the poverty of the blood succeeds an 
acute suppression, and in turn prevents the establishment of the 
flow. A tonic, roborant treatment, applicable to anaemia arising 
from other causes, may be instituted, if need be, even before the 
inflammatory condition of these organs has entirely subsided. 
Perhaps a little more attention to alteratives, in connection with 
the tonics, is necessary in this class of cases. When anaemia is 
the primary condition upon which amenorrhoea depends, it will 
almost always be found to be a sequence to some preceding affec- 
tion. Indigestion, connected with a slow or depraved state of the 
secretions of the alimentary canal, often, by preventing the intro- 
duction of nutritious elements into the blood, induces anaemia. 
These conditions arise, for the most part, in two different ways : 
either the nervous energy necessary to the sustenance of these 
functions is diverted to other objects, as mental training in the 
school-girl, or the circulation in the abdominal organs is too slug- 



80 MENSTRUATION AND ITS DISORDERS. 

gish on account of sedentary habits, as with the sewing-girl. 
Sometimes want of exercise and too great a tax upon the brain 
from studies, anxiety, &c, co-operate in the same individual. 
Anaemia may be produced by a great variety of causes besides 
those above-mentioned, but, according to my experience, these are 
greatly the most frequent. I would not have the reader to believe 
that because I have given the school-girl and the sewing-girl as in- 
stances of amenorrhcea that they are the only persons in whom the 
same character of causes operate in the same way. Too many 
fashionable young ladies, who might enjoy the blessings of relaxed, 
diverted, or healthily employed minds, and appropriate and en- 
livening exercise, become anaemic from sheer laziness, and the 
nervous anxiety connected with envy. 

Bearing in mind, then, the habits which induce indigestion and 
anorexia, we must, first of all, thoroughly revolutionize the habits 
and circumstances of the patient, making plenty of outdoor exer- 
cise one of the main conditions. Riding in a carriage is not out- 
door exercise for these patients, but they must ride a horse, or, 
what is very well, walk, run, and romp. An excellent sort of diver- 
sion for the mind is occupation in domestic duties ; making beds, 
sweeping, caring for and attending children, cooking, washing, 
&c. The mind and body are both employed in a varied and di- 
verse manner in these household duties; and it will be found that 
exercise of body and mind both is most profitable as it is most 
diverse and varied. - While it is true that some kinds of exercise, 
as walking or riding, may be made to call into play a great many 
muscles, yet the whole routine of duties presenting themselves in 
the business of housekeeping, by personally doing the work, is 
more beneficial than all others devised. All this lesson is taught 
by the contrast between the young mistress and her servant. 

In addition to the adoption of a more rational course of habits 
for the patient, much may be done by the judicious use of medi- 
cines. Almost invariably the tonics must be preceded by, or ac- 
companied with, alteratives and laxatives. The stomach will no 
more recognize and respond properly to any tonic that is intro- 
duced into it until prepared, by correcting the secretions, quick- 
ening the gastric circulation, and unloading the bowels, than it 
will digest food under similar circumstances. The alteratives suit- 
able, generally, are mercury in some form, taraxacum, and turpen- 



AMENORRHEA. 81 

tine. When the bowels are torpid, the stools dry and of unnatu- 
ral color, particularly if the color is light, from three to six grains 
of blue mass, given every third night, and followed next morning 
by a seidlitz powder, or sufficient sulphate of magnesia to cause 
one or two evacuations, is an admirable alterative. Ten grains of 
good extract of taraxacum, with a minute quantity, say the twen- 
tieth of a grain, of bichloride or biniodide of mercury, three times 
a day for two or three days, generally does very well. The mer- 
cury should not be given with the taraxacum longer than three 
days, and then intermitted for a week, but the taraxacum may be 
given for weeks steadily forward. An excellent alterative for the 
stomach is Venice turpentine. Ten grains, three times a day, 
after eating, on some sugar, alternated, or given with some of the 
mercurial preparations, proves often of great service. I cannot 
but mention the compound confection of black pepper, made in 
imitation of Ward's paste, as having frequently an excellent laxa- 
tive and corrective effect on a weak state of the stomach attended 
with constipation. I have known it to cure some of the most ob- 
stinate cases of constipation attended with anaemia. 

If there is not scantiness of secretions, but slowness of peri- 
staltic movement, we ought to depend on rhubarb and aloes. The 
compound aloetic pill is a good preparation. In the selection of 
tonics, we should bear in mind the difference between the sto- 
machic and blood tonics. Iron is, perhaps, the only, or almost the 
only, blood tonic directly, while there are a great many articles 
that act as stomachics. Almost all the bitter vegetables ranged 
under that head in the books are useful under certain circum- 
stances. The stomach tonics, by improving digestion, are indi- 
rectly blood tonics, so that they are sometimes all that are necessary. 
In many instances, too, the stomach must be prompted by the bit- 
ters, or other stomachics, before it will absorb or assimilate iron. 
The bitter may be mixed with the iron, precede it, or administered 
simultaneously with it. It is sometimes convenient and profitable 
to combine the alterative and stomach tonic. A mixture of this 
kind, often used, is the compound tinct. cinchona, with bichl. mer- 
cury dissolved in it. The tinct. gentian, or colomba, answers very 
well compounded with mercury. Ext. gentian, and Quevenne's 
iron compounded, in a pill, operate well on the weak state of an 
anaemic patient. If we understand the principle that governs the 

G 



82 MENSTRUATION AND ITS DISORDERS. 

treatment in such cases, we may readily find the means to accom- 
plish our ends, — alterative, stomach tonic, and blood tonic. 

The cachexise, several of which interfere with the regularity of 
the function of menstruation, must be treated as if the menses 
were present in their normal quantity, and in these cases the 
amenorrhoeal complication is of no importance ; hence, special 
efforts to restore the flow are injudicious, and, in most cases, in- 
jurious. 

In patients well developed in most respects, whose genital sys- 
tem is deficient, the menses cannot be produced unless these organs 
grow and become more active. Anything that will stimulate these 
organs will occasionally bring this result about. Wedlock is a 
remedy in these cases sometimes. The indulgence in society, and 
the recreations of it, in company with men, sometimes, through 
the moral faculties, stimulate the genital organs towards develop- 
ment. The stimulus thus afforded by society is one of the bene- 
ficial effects resulting from the change of habits required in young 
girls who go to boarding-schools until sexually dwarfed by con- 
finement to the uninteresting society of their own sex. 

Prof. Simpson has recommended an instrument which he calls 
an " intra-uterine pessary," to bring about this development. It 
is equally applicable to cases of atrophy of the uterus arising 
after the menses have been established. I have had occasion to 
use it, and am now employing it in the interesting case to which 
I have alluded above. It is theoretically better, I am afraid, 
than it will be found practically ; yet there is no doubt much good 
may be done by it. The object of the intra-uterine pessary is, 
1st. By being introduced into the cavity of the organ, and allowed 
permanently to remain there, to cause a development analogous to 
the development around a growing polypus or foetus. If this can 
be effected, the uterus becomes more vascular, and hence is more 
likely to bleed under the stimulus of ovulation ; and, 2dly. To be 
the medium, or generator, rather, of galvanism, to stimulate the 
nerves of the uterus. Both of these objects are promotive of ute- 
rine hemorrhage, if not of correct menstruation. They are nec- 
essary to the development of an atrophied uterus, whether congen- 
ital or acquired. But this instrument is recommended and used 
in obstinate cases of amenorrhoea, where there is no apparent defi- 
ciency in the size and development of the organs concerned. It 



AMENORRHEA. 83 

is in this class of cases that most may be effected by it, and yet it 
sometimes entirely fails to produce any effect. To do good in the 
cases of atrophy and want of development, it should be used 
continuously. Where the development is good, I am inclined to 
think that it will do more good by using it intermittingly. In 
these last we may introduce the instrument, and allow it to remain 
one week before the time of the expected period, and then, after 
the time is passed, remove it, and again introduce it at the proper 
time. We should remember that we cannot use an instrument of 
the same size in all cases. In the uterus that is much atrophied, 
it would be violence to use an instrument that is applicable in a 
case of a fully developed organ. In the former, we must have an 
instrument that will pass into it easily, and in a couple of months 
use one larger ; and after the lapse of a similar time, make an- 
other one still larger, &c, until development is complete. The 
instrument is made of copper and zinc, and consists of a stem 
and bulb. The bulb is hollow, in order to be light as possible, 
flattened, and oval in shape, one inch long, three-quarters of an 
inch wide, and half an inch thick. It should be perforated 
through its thinnest diameter by a hole two-twelfths of an inch 
in diameter. Into this perforation the stem is to be inserted. 
The stem should be two inches long for a uterus not atrophied, 
and as much less as is necessary in the judgment of the atten- 
dant, when atrophy has taken place. It should be hollow and 
light like the bulb. The bulb, and one inch of the stem next the 
bulb, is made of copper, the extremity of the stem of zinc. This 
completes the instrument as made and used by Prof. Simpson. I 
find, in some instances, great difficulty, if not an entire impracti- 
cability, of wearing it, on account of a tendency to fall out. 
Sometimes, too, the gavlanic stimulus is not sufficient. In either 
of these cases I have made an addition to it, which, I think, adds 
to its efficiency as well as security of position. This consists of 
a zinc ball, about an inch in diameter, attached to a copper rod 
four inches long. The bail is introduced into the vagina after the 
intra-uterine pessary has been introduced, while the stem is at- 
tached to a framework outside the pelvis, to keep the whole in 
position. As will be seen by a study of this apparatus, we have 
quite a galvanic battery, — the copper rod reaching from the frame- 
work of zinc outside to the zinc ball inside, this last lying in con- 



84 MENSTRUATION AND ITS DISORDERS. 

tact with the copper bulb of the pessary, &c. If we do not de- 
sire any galvanism in the case, the whole apparatus can be made 
of copper. Made in this way, the instrument is quite efficient. 
The young physician or student may be embarrassed in his at- 
tempts to introduce the pessary without a little consideration. 
The plan I have found most convenient is, to expose the os uteri 
by means of the quadrivalve speculum ; secondly, to secure the 
pessary by inserting a piece of whalebone, properly shaped, in the 
perforation in the bulb ; thirdly, thus mounted, to insert the stem, 
and with great gentleness, urge it forward to its full length, or 
until it is arrested by the contracted internal os uteri, or the end 
touching the fundus. If this arrest occurs, the instrument is 
either too large, or too long, and must be replaced by one more 
suitable in this respect. After the pessary is inserted, we may 
withdraw the speculum, and, if necessary, apply the ball and ex- 
ternal framework above described to keep it in position. All this 
direction does not include a fact which should ever be borne in 
mind by the student, viz., that the instrument is sometimes utterly 
intolerable ; and, at others, a good deal of address and patience 
is required to habituate the parts to it. The patient should be 
forewarned that pain and inflammation are the possible effects, 
and that she must inform us should they be considerable. There 
is always some pain, sometimes a great deal. When the irritation 
is too severe, the instrument must be removed, quietude observed, 
and, if necessary, anodynes, and even antiphlogistic treatment, to 
remove the symptoms. After all these have subsided, it may be 
again introduced. A little perseverance and care will render most 
cases tolerative of its presence. During the time the instrument 
is used, the vagina must be thoroughly cleansed, at least twice a 
day, with tepid, warm, or cold water, and some fine soap, used as 
injections. 

Obstructions to the flow of the menstrual blood must be re- 
moved by the finger, when practicable ; when not, by the knife. 
In recent, and sometimes in cases of long standing, the adhesions 
may be torn through by pushing the index finger forcibly against 
them. If the obstruction is caused by the hymen, this may gen- 
erally be done. This failing, we should introduce first an explor- 
ing trocar into the containing sac, and guided by this, freely in- 
cise, by means of a tenotomy knife, the most dependent part. The 



AMENORRHEA. 85 

incision must be made in the lateral direction, being careful to 
avoid the bladder and rectum. These two organs ought to be 
emptied previous to operating. The opening ought to be free, the 
blood all evacuated, and the cavity in which it was contained thor- 
oughly washed out with tepid water. The opening will have a 
tendency to close, and partially or wholly restore the obstruction. 
We can avoid this best by introducing the finger every day for 
two or three weeks. The injections into the uterus must be re- 
peated twice a day for the first ten days or two weeks. As the 
cavity decreases in size, we should be careful to adapt the instru- 
ment to this circumstance. From the time the operation is per- 
formed, the patient should be carefully watched, as there is often 
a strong tendency to peritoneal inflammation soon afterward, which 
not unfrequently proves fatal. When there is much pain, a full 
dose of opium, administered and repeated afterward as often as 
necessary, will go very far towards averting such evil. Toxaemia 
is another danger to which the patient is subjected, and is to be 
avoided only by the thorough cleansing of the cavity I have de- 
scribed. When either of the sequences do occur, their treatment 
will, of course, be governed by the same principles as if they orig- 
inated under other circumstances. 



CHAPTER VI. 

MENOKKHAGIA. 

Hemorrhage occurring at the time of menstruation beyond the 
usual quantity for the patient, is menorrhagia. Hemorrhages oc- 
curring at other times do not belong to this denomination. Often 
there are both hemorrhage and menorrhagia in the same individ- 
ual, which depend upon the same conditions of the system or re- 
productive organs, and are alike symptomatic of some local or 
general disease. It ought never to be forgotten that menorrhagia 
is a symptom and not a disease, and that we must look beyond 
the discharge for indications of treatment. Unfortunately, we 
cannot always discover the conditions in which it originates, and 
consequently are often left to conjecture. 

In considering the pathology of menorrhagia we must make two 
general divisions. 1st. Those cases in which the reproductive 
organs are at fault ; and 2d. Cases in which, with a healthy con- 
dition of these, there is general disease, found in the blood for the 
most part. These two are sometimes combined. The former is 
by far the more frequent. Local causes operating upon the uterus 
and ovaria are more commonly efficient than the general conditions 
which sometimes give rise to it. 

Chronic inflammation of the mucous membrane lining the cavity 
of the corpus or cervix uteri, or both, is, in my observation, a con- 
dition attended with menorrhagia in a great many instances of 
this affection. In young persons this is particularly the case. 

There are cases also of general inflammation of the uterus at- 
tended with menorrhagia, which, when the inflammation is cured, 
'the patients are no longer the subjects of this symptom. Tempo- 
rary congestion of the uterus from long standing, too much heat 
about the pelvis from heavy clothing, excitement from any cause 
at the time of menstrual congestion, too great indulgence in sexual 
intercourse, sometimes excite temporary menorrhagia. The mu- 
cous membrane of the uterus is sometimes covered more or less 



MENORRHAGIA. 87 

completely with little vascular growths, not large enough to be 
called polypi, that bleed at the time of menstruation. Sometimes 
one or more minute, hardly distinguishable fibrous growths, in- 
truding into the mucous membrane of the cavity, or embedded in 
the walls, render the organ more than naturally vascular, and con- 
sequently liable to bleed more at the time of menstruation. Larger 
polypi of a soft or hard nature, existing in the cavity or attached 
to the cervix, are first suspected on account of increased menstrual 
flux. 

Common ulceration, by inducing permanent congestion, is often 
attended with menorrhagia, but almost always the malignant ulcer- 
ations, as cancer, &c, give rise to increased discharge of blood at 
each menstrual period. 

Tumors situated near the uterus, so as to press upon the veins 
which carry the blood away from this organ, induce hemorrhage 
and menorrhagia. Cancer, chronic inflammation, or other organic 
diseases in the ovaria, not unfrequently give rise to this symptom. 
In fact, any local disease in the pelvis that acts as a focus of con- 
gestion, may do the same thing ; therefore, hemorrhoids, prolapse 
of the rectum, chronic inflammation, polypi, common or cancerous 
ulceration, are sometimes attended with this effect. 

I can readily see how displacement, particularly if attended 
with inflammation, may act as a causing condition ; but I think its 
effect in this respect is overrated by some authors. 

The general conditions attended by menorrhagia are not very 
numerous, but some of them are undoubtedly efficient operating 
causes. Plethora from high living and indolent habits, from heredi- 
tary predispositions in persons beyond thirty years of age, gen- 
erally from intemperance and other irregular habits, &c, may be 
enumerated among them. I think I have known two patients af- 
fected with menorrhagia from a possession of the hemorrhagic di- 
athesis, so well established by the observations of surgeons as being 
the cause of hemorrhage of a different nature. These general con- 
ditions seem to act by causing a rich and abundant state of the 
blood, which gives rise to rupture of the capillaries from the stress 
of undue distension. The opposite states of the circulating fluid 
may also be attended with menorrhagia ; hence we have this symp- 
tom from anasmia, or watery condition of the blood, if this is a cor- 
rect expression. My idea of aneemia is exemplified by the condi- 



88 MENSTRUATION AND ITS DISORDERS. 

tion of the blood when deprived (from whatever cause) of a large 
portion of its globules ; plethora, when there is a. relative increase 
in the amount of globules. Either of these conditions may be at- 
tended with a relative increase or decrease of any of the other 
ingredients of the blood, except, perhaps, water. They may also 
be complicated by the retention or introduction of poisonous ingre- 
dients, — septicemia. In anaemia there is probably, at least in 
many instances, no great reduction in the amount of fluid in the 
vessels ; and hence, so far as the fulness of the vascular system is 
concerned, we may have plethora. I think the hemorrhages and 
monorrhagia that result from the watery condition of the blood, 
are often, if not generally, brought about by undue stress upon 
the capillaries of the organ from which the flow takes place, and 
not because of the thinness of the blood, which, as is supposed by 
some, enables it to permeate the walls of these minute vessels. 

Anaemia resulting from indigestion, confinement, depressing pas- 
sions, deprivation and toil, damp low situations, miasm, and de- 
generation of the kidneys, all induce monorrhagia occasionally. 
More occult causes of anaemia, such, indeed, as are inscrutable in 
their action, may be expected to exist. 

The peculiar condition of the blood — which, if not anaemia, re- 
sembles it more nearly than the opposite condition of the circula- 
ting fluid — brought about by albuminuria, should be suspected 
when any of the symptoms indicating it present themselves in 
females who have suffered from eclampsia in their first confine- 
ment, or in patients approaching the climacteric period of life. 
Scurvy has seemed to me, on several occasions, to give rise to 
menorrhagia. During a prevalence of this affection in my circle 
of acquaintance one year, among the German population more 
particularly, in consequence of their inability to procure proper 
vegetable diet, menorrhagia was a very troublesome symptom. 

The above are most of the obvious conditions of menorrhagia, 
but there are instances which cannot be traced to any of them, 
or any other state of the system or particular organs. It is be- 
lieved, however, that they are the exceptions, and that, a careful 
survey of each individual case will enable us to get a clue to con- 
ditions so obvious as to warrant us in using them as a basis for 
treatment. Constipation, whether it be regarded as a general or 
local affection, always acts mischievously on the uterus, and when 



MENORRHAGIA. 89 

there is a tendency to menorrhagia it will be aggravated by this 
condition of the bowels. And perhaps in some instances costive- 
ness may of itself be sufficient to induce menorrhagic congestion 
by obstructing the circulation. 

Diagnosis. — This is not generally difficult, so far as making up 
our judgment merely as to its existence is concerned, but, as al- 
ready intimated, it is often exceedingly difficult to get precisely at 
the conditions which give rise to it. Individuals must be judged 
by their own standard as to the quantity of menstruation. What 
would be too much for one would be an ordinary quantity for an- 
other. If a woman who has been in the habit of losing twenty 
ounces of blood at each menstrual period from the beginning of 
her menstrual life, is in the enjoyment of good health, and suffers no 
inconvenience from it, that may be regarded as her normal quan- 
tity. If, however, for several years six or eight ounces was her 
ordinary limit, and her health is affected injuriously by the in- 
creased flow, twenty ounces must be considered menorrhagia, and 
treated accordingly. The general standard must be very carefully 
erected. Probably an average quantity of loss in health is not far 
from eight ounces. Many lose much more, some much less, and 
yet all may be equally well and healthy in the discharge of this 
function. 

It may be well to instruct the student how to measure the quan- 
tity lost. As women generally wear napkins over the genital 
fissure at such times to protect their clothes, we may judge cor- 
rectly enough for practical purposes, by inquiring the number 
saturated each time. One napkin will require an ounce of blood 
to thoroughly saturate it. Counting each one soiled as an ounce 
of blood lost, we can easily ascertain the quantity. Having de- 
termined that menorrhagia exists, whence does it originate? 

The symptoms of general suffering when menorrhagia has be- 
come an inveterate symptom, are often grave, but not peculiar. 
There is much of a'sameness in suffering from any form of uterine 
disorder or disease. Nervous pains in the head, back, groins, peri- 
neum, hypogastrium, lowness of spirits, indigestion, and legions of 
disagreeable symptoms, which no man can enumerate, but which 
all experienced physicians who have treated diseases of females 
must have witnessed, and set down as uterine, will be found to 
attend upon them. The obligation to determine the causing con- 



90 MENSTRUATION AND ITS DISORDERS. 

dition of menorrhagia is imperative, as without this knowledge our 
treatment is entirely empirical and uncertain. 

First of all we should try to fix upon the distinction between 
the general and local conditions. I need not enter minutely into 
the consideration of the circumstances and symptoms of the gen- 
eral conditions. I will, however, caution the reader not to mistake 
the cause for the effect ; for, as will readily suggest itself, anaemia 
is one of the effects of menorrhagia, and if we do not get an in- 
telligent history of our patient, we may fall into this error. With 
proper caution we may satisfy ourselves which was first in the 
chain of circumstances, the anaemia or the bleeding. When we 
suspect albuminuria, a test of the urine will enable us to decide as 
to its existence ; when we have decided that a given case is not of 
general origin, we are to investigate the condition of the pelvic 
organs. 

I need not dwell upon the mode of examining them, as full di- 
rections for this purpose are given elsewhere. It should be thor- 
ough when there is obscurity, and conducted so as to reach all the 
organs in the pelvis, but especially the uterus, which is the organ 
much the most frequently at fault. The finger, speculum, probe, 
and, if need be, the dilating influence of the compressed sponge, 
should be brought into requisition. In obstinate and otherwise in- 
scrutable cases, any doubt may be cleared away by dilating the 
cervix so as to feel, and, if need be, see the cavity of it and the 
corpus uteri. Any excrescences, vascularities, or other abnormal 
condition, would thus be discovered, and be placed in a condition 
to be removed or corrected. 

Prognosis. — Immediately, there is not much danger in menor- 
rhagia, though there are instances on record of its proving fatal 
by reason of its immediate effects, the patients literally bleeding 
to death. Dr. West gives one instance of this kind, and speaks 
of another that came to his knowledge. There were no signs of 
pathological lesion, in either case, discoverable by dissection, that 
could account for their disastrous termination. This event is, 
however, undoubtedly very rare. 

A much larger number of cases prove disastrous indirectly, by 
inducing other diseases. The loss of a large quantity of blood 
impairs the functions of all the important organs. Nervous and 
cerebral affections arise thus. We may trace to this circumstance 



MENORRHAGIA. 91 

sometimes obstinate forms of indigestion, hepatic and splenic con- 
gestions, &c, &c. In various ways, indirectly, these losses affect 
the health injuriously, and, acting conjointly with the causing 
condition, it would be surprising if grave cases of menorrhagia did 
not do so much mischief to the general organization as occasion- 
ally to prove fatal. Another point in the prognosis, of very great 
interest, is its curability. Can it be cured by judicious scientific 
treatment ? This question can be answered in each case only by a 
scrutinizing examination of the individual circumstances connected 
with it ; and will depend for its solution upon the character of the 
causing conditions, the length of time it has been in existence, 
and the effects already produced by it upon the general health of 
the patient. 

The general statement, that very great benefit can be derived in 
almost all cases, and a cure very generally be made, may properly 
be ventured upon. 

In coming to a prognosis, we must bear in mind the influence 
which a long-established habit has in keeping up the discharge 
after the causing condition has been removed. The physician and 
patient should, therefore, not be discouraged at the slowness with 
which the curative effect of the treatment is produced. 

Treatment. — The treatment is palliative and curative. The 
palliative has for its object the relief of the hemorrhage; to pre- 
vent it from being excessive until the period passes by, when it 
will spontaneously subside. The curative is intended to remove 
or cure the causing condition. In conducting the palliative treat- 
ment, we may very properly commence before the time for the ap- 
pearance of the menses. We ought especially to rectify and re- 
move the circumstances that aggravate it. We will often find 
constipation an aggravating accompaniment. In such cases, it is 
well to give ten grains of blue pill, the fourth and second night 
before the expected attack, and follow it in the morning each time 
with a saline cathartic. This removes the abdominal plethora for 
a time, and prepares us for an antiphlogistic regimen, which 
should be strictly observed where there is general plethora, for 
two or three days before, and during the time of the flow. The 
diet should be light, and taken cold ; and the patient may take 
the twentieth of a grain of tartarized antimony four or five times 
a day, or, what I have thought sometimes better, ten grains of 



92 MENSTRUATION AND ITS DISORDERS. 

nitrate of potassa as frequently. The patient should also assume 
the recumbent posture for two or three days beforehand, and be, 
as far as possible, free from all causes of mental excitement. All 
these precautions are intended, of course, only for cases of serious- 
ness and gravity. To some extent they may, with propriety, be 
resorted to in most cases. The cathartic, rest from fatigue, cool 
diet, &c, will always be comfortable as well as profitable. 

It is a difficult matter always to command the co-operation of 
our patient in such measures as are necessary to moderate the 
hemorrhage after it has begun. There is a popular fear of the 
consequences of using measures to stop the menstrual discharge ; 
and I have known medical men who always allowed a certain 
amount of blood to escape, and time to elapse, before they would 
put in requisition such measures as they considered most effective. 
There can be no question about the propriety of beginning with, 
and even anticipating, the time, by the use of the most energetic 
means to arrest the discharge. The danger is that they will fail, 
and not that they will be too prompt in their action. So far as 
we can, we ought to be governed by the general condition of the 
system and the uterus in the choice of our remedies. If the phlo- 
gistic pulse and general habit of the body are obvious, and steadily 
maintained through the first days of the attack, our remedies must 
be mainly directed against the condition thus indicated. Anti- 
mony, or nitrate of potassa, have always been favorite remedies 
in such cases with me. Now, sometimes, when I can anticipate the 
attack in this class of patients, I am in the habit, in addition to 
the nitrate, to bring about the influence of veratrum viride, and 
keep the patient moderately under it during the whole time. It 
is in this condition that the digitalis, so strongly recommended 
by Dr. West, will be found most beneficial. He recommends us 
to give 5iv of the infusion every four hours. It is but fair to 
state that Dr. West does not advise it in this class of cases only, 
but says, " The existence of a very considerable degree of exhaus- 
tion, and the necessity for the administration of wine, do not con- 
traindicate a trial of digitalis." He gives it in these cases, how- 
ever, in only 5ii doses to begin with. The digitalis should be 
continued until some dizziness or sense of faintness is produced, 
when it should be stopped. 

In cases where the hemorrhage is more passive, and unattended 



MENORRHAGIA. 93 

with arterial reaction, the general treatment must be different. 
Very frequently the uterus is enlarged and lax of fibre, and the 
remedies must be such as will condense its tissues, as ergot, borate 
of soda, alum, and strychnia. Probably turpentine should be 
mentioned second to ergot in this connection; it is certainly very 
effective in many instances. The ergot should be given in large 
doses. My mode of administering it is the same as in cases of 
labor. Twenty grains of the powder in water that has been poured 
upon it boiling hot, and allowed to stand until cold. This should 
be repeated as often as once an hour for three or four times. 
Whatever the effect, we should then wait for the lapse of twelve 
or eighteen hours before having recourse to it in the same way. 
In the course of the paroxysm, it may be profitably used four or 
five times, if necessary. 

In this way ergotism may be produced, and after wearing off, 
which it is apt to do in less than twenty-four hours, reproduced. 
Turpentine should also be given in large doses ; 5i every four 
hours, in an emulsion, is very effective. In threatening cases it 
may be given even in larger doses, 5ii 5 for instance, every five 
hours. Its effects are ordinarily more marked than those of any 
other remedy, not excepting ergot. Acet. lead, and the vegetable 
astringents may all be tried, but I have not had much good result 
from them at such times. Positive quietude is indispensable to 
the success of every general course of treatment. In cases at- 
tended with great pain and suffering in the region of the uterus, 
full doses of opium sometimes produce admirable results. In ad- 
dition to this general treatment, and ice-cold drinks, there is a cer- 
tain kind of local treatment, applicable alike to almost all sorts of 
severe cases. We may always use cold to the hypogastric region. 
Ice in a bladder, or piece of oil silk, is the best application of this 
sort ; or, if in winter, frozen wet cloths make an excellent appli- 
cation. Small pieces of ice, introduced into the vagina as near 
the os uteri as can be, ought to be used, as affording valuable aid. 
Copious ice-water injections is sometimes more effectual than any 
other local remedy of this kind I have tried. I have not seen any 
bad effects from this free use of cold internally. 

In cases of peril or great exhaustion, the tampon is a valuable 
means of relief. It is not best to wait long enough for the patient 
to become greatly exhausted, in cases where our former observation. 



94 MENSTRUATION AND ITS DISORDERS. 

teaches us the flow will continue, or where we have tried the above 
treatment without moderating the discharge, but we should at once 
resort to the tampon. 

For several years I have not used any other form of tampon 
than the gum-elastic air-bag. It may be found in almost any of 
the shops at present, and if its tube is properly supplied with a 
stop-cock, it makes the handiest and, I think, the best in use. It 
can be introduced up to the mouth of the uterus while empty, and 
then by means of the inflater, which goes with it, distended to any 
desirable dimensions. In cases of this kind, it ought to be inflated 
until it produces slight sense of pain in the vagina from distension. 
This pain will soon pass off, and with it the vagina may slightly 
dilate ; when that is the case the distension may be increased. 
It should not be allowed to remain in the vagina longer than 
twenty-four hours, without being removed and cleansed. The va- 
gina should also be syringed with cold or even ice-water. After 
these things have been done, it may be again introduced, and so 
on as often as necessary. The physician may use cold water in a 
gum-elastic bag, in place of air, if he choose, but it is not so con- 
venient, and probably not much, if any better ; as, by distension, 
the instrument may be pretty certainly made to check the hemor- 
rhage. 

By employing such judicious and sufficiently energetic means as 
"we may command, we will very greatly relieve the extreme cases ; 
and sometimes the repeated interruption of the discharge proves 
curative. This will be the case most likely when the hemorrhage 
outlasts the condition which originally produced it, which is not 
very common. In most instances, it will be necessary to place 
our patient under proper treatment during the intervals. The 
object of the curative treatment is to remove the causing condi- 
tion, which should be carefully ascertained when at all practicable. 

We have seen that anaemia is occasionally an efficient causing 
condition. When this condition is uncomplicated, it is almost al- 
ways produced, more directly, by a failure on the part of the di- 
gestive apparatus. I do not think it would be proper here for me 
to do more than indicate a few general principles by which to be 
governed in the management of anaemia. Almost always we need 
medicines and management, to give muscular tone to the stomach 
and bowels, a healthy state of the secretions in the whole of the 



MENORRHAGIA. 95 

alimentary canal, and more directly to add iron to the blood. We 
must effect perfect chymification, chylification, sanguification, and 
defecation ; and if any of these processes is imperfectly per- 
formed, the result will not be attained. We cannot, in most 
cases, simply give iron with the hope of causing better sangui- 
fication. The first two steps of digestion must be well performed 
before good rich blood can be made, however much iron we may 
pass into the stomach or blood, were that possible. Then defe- 
cation, to keep separate the effete materials of the ingesta, is just 
as necessary to the formation of pure blood. We, to be sure, oc- 
casionally meet with cases that may be cured by any process 
that will correct one of these derangements, but this certainly 
is not common. By examining carefully each case as it comes up, 
we generally ascertain which one of these processes is most at 
fault. But we must not only furnish the vessels with well-di- 
gested material, but, to perfect sanguification, we must introduce 
oxygen in sufficient quantities, or we meet with failure still. In 
more special terms, our anaemic patients will need the bitter tonics, 
and, generally, some stimulants given at meal-time, so as to stimu- 
late the stomach at the time of digestion, get mixed with the 
chyme, and pass with it through the duodenum and jejunum, and 
not be absorbed wholly until taken up with the chyle. Iron may 
be superadded to these, more directly to enter the vessels ; and 
probably two hours after eating is the best time to administer 
it. For the purpose of promoting proper secretions, a few grains 
of blue mass, administered every second or third night, to be 
followed in the morning after with a saline laxative, large enough 
merely to move the bowels gently, has seemed to me to suit very 
well generally. Then there are some substances that may be added, 
if thought best, more directly to act upon the muscular portion 
of the alimentary canal ; as strychnia and ergotine, both of which 
may be employed in certain cases, to great advantage. Or, if we 
prefer, we may use five grains of pulverized nux vomica, or pow- 
dered ergot, in place of their alkaloid principles, three times a day. 
By keeping in view these leading ideas of the pathological 
causes of anaemia, and the modes of relieving them, the treatment 
will be comparatively simple and efficacious. Healthful muscular 
exercise in the open air, at least one-fourth of the twenty-four 
hours, and proper diet, will be indispensable addenda to these. 



96 MENSTRUATION AND ITS DISORDERS. 

But we should not forget that, generally, underlying all these 
things, there may be a cause that it will be necessary to remove. 

In women, the uterus may be diseased, or the genital organs 
may be abused by masturbation. We should examine carefully, 
in order to ascertain the originating difficulty. 

Ursemic anaemia, for I think this is the condition albuminuria 
usually indicates, is, happily, of more rare occurrence; and it is 
unfortunately, also, much more difficult to manage. Iron, ergot, 
and the terebinthinates, — the balsam copaiba particularly, — are 
the most useful means in such cases. The tincture of iron in 
pretty large doses, say forty drops three times a day after eating, 
is extremely useful. It should be administered during the inter- 
vals ; and a few days before the attack, it may be omitted for five 
grains of the powdered ergot three times a day. One capsule of 
balsam copaiba, containing half a drachm, may be given in place 
of the iron, followed by the ergot. Such use of these remedies, 
although generally incapable of restoring the function of the kid- 
neys, often improves the symptoms very much. 

General plethora may accompany menorrhagia, but I think very 
seldom. Plethora, or rather congestion of the abdominal organs, 
is quite common ; and the judicious management of it will afford 
great relief, if it does not cure the symptoms. I need not dwell 
at any great length on the subject in this place, as I have already 
spoken of it in the treatment of the paroxysm ; but I must refer 
to the great benefit I have seen result, where this condition was 
prominent, in the use of minute doses of bichloride of mercury, 
and large doses of taraxacum, administered for a long time. 

In one of the first cases I ever treated, — and one in which the 
most marked benefit resulted, — I put §ii of the extract of tarax. 
in Sxvi cinnamon-water, and then dissolved gr. i of corrosive 
chloride of mercury in it. The patient took a large tablespoonful 
of this mixture three times a day. Slight ptyalism occurred in 
three weeks from the time she began to take it ; the paroxysm 
came on in three days after this occurrence ; the discharge was 
very greatly reduced. The same process was repeated the next 
two months, when the patient was entirely cured. 

When the hemorrhage depends upon endometritis, which, I 
think, is very frequently the case, the disease is to be treated as 
directed in another part of this work. (See Endometritis.) 



MENORRHAGIA. 97 

When inflammation of the body or cervix uteri is present, our 
treatment will be ineffective, as a general thing, until it is re- 
moved. And we should look and expect their presence in a great 
many instances. Subinvolution and the congestive or hyperaemic 
condition, which often accompany it, are not unfr'equently the 
obstinate causes of menorrhagia. These conditions may be re- 
moved with a good deal of certainty by patient and persevering 
treatment. The treatment I have found most effectual is the ap- 
plication of nitrate of silver to the inner surface of the organ 
pretty thoroughly every seven or eight days. This stimulates the 
uterus to contraction and condensation, and in the course of four 
or six months the difficulty may be entirely removed. We should 
be sure to persevere long enough. On theoretic grounds, we might 
expect ergot and strychnia, administered for a length of time, to 
lead to the condensation of the uterus tissues ; but I have so gen- 
erally cured this class of cases by the local application of the nitrate 
of silver to the inner mucous membrane of the uterus, that I con- 
fess I have but little observation with any other treatment. These 
strong astringent applications to the inner surface of the uterus, 
made by the flexible caustic-holder, or the whalebone with cotton 
or lint upon the end of it, will generally cure those cases that are 
kept up by too great vascularity of the mucous membrane. We 
may thus introduce the nitrate of silver in substance, and apply 
it thoroughly to the inner surface, by freely moving the caustic- 
holder about in it, or if we fail in making a strong impression, a 
small piece of the nitrate may be left in the cavity to dissolve and 
diffuse itself. I have done this a number of times, and with the 
exception of trifling pain, lasting only for a few hours, and some 
sanguineous discharge for two or three days, have had no bad result. 

The application of the nitrate to the inner surface may be done 
once a week with the caustic-holder, and in general will succeed 
well. The acid nitrate of mercury may be used with the whale- 
bone probang once in two weeks, when the nitrate of silver is not 
used. Creasote, muriate tinct. of iron, and, in fact, all the reme- 
dies I have recommended for endometritis can be used in the way 
recommended under that head. But it sometimes happens that the 
menorrhagia continues in spite of this treatment, and I think gen- 
erally on account of the imperfect applications to the inner surface 
of the uterus. It then becomes a question whether the os and 



yo MENSTRUATION AND ITS DISORDERS. 

cervix ought to be dilated. I think that when the bleeding resists 
all other judicious means for its arrest, this measure is justifiable, 
and, if the loss is great, demanded. We may have two objects in 
view in resorting to dilatation : 1st, to ascertain the precise con- 
dition of the cavity of the uterus when practicable in this way, 
and 2d, to be able to remove any small growths that may be found 
there, or to make a thorough application to the mucous membrane. 
In one instance, not long since, I cured the menorrhagia by dilat- 
ing the os and cervix so that I could introduce my finger to the 
fundus, and then with a cotton swab cauterizing the membrane 
thoroughly with acid nitrate of mercury. I operated this way 
twice, at intervals of two months. There was but little incon- 
venience from its use, and the case was entirely cured. We should 
be careful to cure, if possible, all local complications of menor- 
rhagia, as having a very important bearing upon our success. 
Hemorrhoids should be particularly attended to, as keeping up and 
aggravating the discharge. Chronic vaginitis, urethritis, cystitis, 
&c, or any disease in the pelvis that keeps up constant congestion 
of the parts, should be remembered as quite worthy of our notice 
in this connection. If ovaritis be complicating the case, it should 
be treated by the means which would be used were it an inde- 
pendent affection. Ovarian inflammation is supposed to have an 
important relation to this and other menstrual aberrations in 
two ways, 1st, by its directly stimulating the uterus by unusual 
manifestation of ovarian orgasm, and 2d, by acting, from prox- 
imity, thus keeping up a large flow of blood to the whole pelvic 
viscera. 



CHAPTER VII. 

DYSMENORRHEA. 

Dysmenorrhea means painful menstruation, or difficult men- 
struation with pain. Menstruation may be attended with severe 
suffering, when the flow is not otherwise attended with perceptible 
improprieties. It may be performed with difficulty, as when the 
flow is prevented by obstruction, or when a membrane is expelled 
with great pain. Whether there is a class of cases in which the 
flow is established slowly and imperfectly at first, or membranous 
productions are expelled without pain, I am not informed ; but 
I have certainly seen instances in which both these conditions 
were present with a very trifling amount of pain. To be dysmen- 
orrhea, the pain must occur at the time of the menstrual epoch, or 
immediately before or after it ; and it must emanate from, if it is 
not confined to, the pelvic region. It is taken for granted, also, 
that it is necessarily connected with this process. The pain is 
not always seated in the uterus ; it may be in the ovaria, in the 
plexus of nerves supplying the uterus, or the lower extremities ; 
or it may be in the bladder, rectum, or urethra, one or more of 
them. And in some cases it seems to occupy all these organs and 
plexuses of nerves. 

A question has often occurred to me in this connection, which 
I think of great interest to decide in each case. Is the pain al- 
ways dependent upon a morbid condition of the uterus or ovaria, 
or is the pain dependent, in some instances, on the morbid condi- 
tion of the organ in which it is located, the rectum or bladder, for 
instance, influenced by the normal congestion of all the pelvic vis- 
cera at the time of menstruation ? I think I have met with cases 
of this last kind. From this mode of viewing the subject, we 
might expect that any pelvic organ, in a state of chronic inflam- 
mation, may become very painful by having the inflammation ex- 
aggerated, as a consequence of the menstrual moiimen ; or any 
pelvic organ, with strong neuralgic proclivities, may become af- 



100 MENSTRUATION AND ITS DISORDERS. 

fected severely by the hyperesthesia of that period. Thus arises 
the sciatica, and other neuralgia of menstruation ; the disease not 
being in the uterus, or ovaria, but in the nervous plexuses, and 
the suffering rendered paroxysmal by normal periodical congestion 
of them as the effect of the menstrual molimen and hyperesthesia. 

These cases are not painful or difficult menstruation, although 
the menstruation is attended with pain. 

The pain of dysmenorrhoea is not only differently located, occu- 
pying different organs and tissues, but, as might be readily inferred, 
different in character. Sometimes it is neuralgic, sometimes in- 
flammatory, sometimes tenesmic, and again, it may combine all 
these qualities ; terrible lancinating or shooting pain, accompanied 
with distressing aching, burning, and bearing down. The pain 
may also be of a cramping or spasmodic character. 

I make these remarks to show the student that the study of dys- 
menorrhoea is not a very simple one, and that if his views of the 
subject are not somewhat comprehensive, his inferences and prac- 
tice will fall short of the requirements of the case, and that an 
examination which does not embrace the whole assemblage of pel- 
vic organs and tissues will be imperfect. Nor can the nature of 
dysmenorrhoea be understood by confining our investigations to 
the pelvis ; but the blood, the nervous system, and abdominal or- 
gans, will sometimes be at fault, and demand attention in a search- 
ing investigation of the subject. 

"While the above statements are true in regard to the general 
subject of dysmenorrhoea, and should be always present in our 
minds, the majority of cases are more simple, and not difficult of 
comprehension, and confined in their nature to some appreciable 
morbid state of the uterus or ovaria. Hence the propriety of the 
divisions entertained by most authors, and which are supposed to 
render the subject more lucid and comprehensible. 

The divisions which I think sufficiently comprehensive to em- 
brace almost, if not all varieties, are, 1st, inflammatory ; 2d, neu- 
ralgic ; and 3d, membranous. Some authors enumerate many 
more, such as congestive, obstructive, &c. I need not mention all 
of them, as they will readily recur to the reader. It is hardly ne- 
cessary to point out how a uterus, in a state of inflammation, may 
become the seat of very great pain at the time its vessels are ren- 
dered excessively turgid by the menstrual congestion. The in- 



DYSMENORRHEA. 101 

flammation and, consequently, the pain, may be in the ovary, 
instead of the uterus, when the same obvious reasoning would be 
applicable. Hence another subdivision of dysmenorrhoea, — ovarian. 

The congestive variety of authors properly falls under the in- 
flammatory form. Congestion recurring at every menstrual period, 
so far beyond its ordinary bounds of moderation as to give rise to 
excessive suffering, without some permanent morbid state of the 
parts, is certainly very improbable ; and, judging from my own 
observation, which, of course, is not so extensive as many observ- 
ers, does not take place. In other words, I have not seen a sim- 
ple case of congestive dysmenorrhoea, but I have seen numerous 
instances in which the inflammation was very moderate but per- 
sistent, and, aggravated by the recurring congestion, and seemed 
to me to be the cause of the pain. This has been proven, too, by 
the removal of the inflammation, and contemporaneous subsidence 
of the dysmenorrhoea. To add to the difficulty, and even perplex- 
ity of the subject, however, I must acknowledge that painful men- 
struation is not always present Avhen inflammation exists in the cer- 
vix. It is with some timidity I state my conviction, that the obstruc- 
tive dysmenorrhoea of authors should be arranged under this head. 

From the time of Dr. Mcintosh's writing on this subject, his 
doctrines, in this respect, seem to have been received as true, uni- 
versally. Notwithstanding this universal agreement of able and 
experienced authors, I must be permitted to express the opinion that 
the idea does not have its foundation in fact. If obstruction to 
the flow of the menstrual fluid is sufficient cause for the exces- 
sive suffering of dysmenorrhoea, why not have these terrible pains 
when, from adhesion of the cervical canal, or external os, the flow 
is entirely prevented ? I am sure, also, that these symptoms do not 
frequently coincide with a very small opening ; that the internal 
and external ores are often both very much contracted, without 
giving rise to any pain daring menstruation. During the time 
that my attention has been specially directed to this subject, I 
have examined many patients in whom the external os was so small 
as to scarcely admit one of Anel's probes, and yet they menstru- 
ated freely and easily through it. Indeed, I have not seen an in- 
stance of dysmennorrhoea from obstruction, while I have seen many 
cases in which the conditions were present, and they ought to have 
existed, according to the doctrine of obstruction, but did not. 



102 



MENSTRUATION AND ITS DISORDERS. 



Dr. Bennett (page 229, of his work on the Uterus) speaks of 
what he calls a marked illustration of this class of cases. After 
attempts at dilatation, not sufficient to allow the probe to enter the 
uterus through the os internum, the patient was entirely relieved. 

I must respectfully decline to believe the correctness of his in- 
ference in this case. It may be asked how I would account for 
the relief afforded in these cases by dilatation ? The bougies, 
sponges, or other foreign bodies, frequently introduced to "dilate" 
the os and cervix uteri, cure or relieve the inflammation. The 
treatment, in fact, is one of the best kind to speedily modify the 
painful character of the inflammation. Dr. Bennett lays great 
stress upon the entire immunity from suffering between menstrual 
periods, and yet, in another place, says that this is possible with 
the existence of inflammation. 

Whatever may be the difference in theory, however, from the 
testimony of Sir James Y. Simpson and Dr. Sims, there are many 
cases very much benefited by operations upon the cervix, and I 
think I can do no better than to give a synopsis of the conditions 
upon which Dr. J. Marion Sims thinks dysmenorrhoea depends. 
In his recent most excellent work on Uterine Surgery, published by 
William Wood & Co., he says (page 142), " It (dysmenorrhoea) is 
only a symptom of disease, which may be caused by inflammation 
of the cervical mucous membrane, retroflexion, anteflexion, fibroid 
tumor in one wall of the uterus or the other, contraction of the 
os externum, flexures of the canal of the cervix either acute or 
greatly curved, either at the os internum, at the insertion of the 
vagina, or extending throughout the whole length of the canal, all 
of which are but so many mechanical causes of obstruction which 
must be recognized and remedied if we expect to cure the dys- 
menorrhoea." 

The following table is on page 132 : 



Of 100 cases of painful menstruation, 



Of 29 cases of excessively painful men- 
struation, . 



os was normal in but 








6 


os was contracted in 








90 


cervix was flexed in 








61 


congested in . . ^ . 








7 


there were polypi in 








2 


os was normal in 











os was contracted in 








26 


< cervix was flexed in 








. 23 


had polypi in . . . 








2 


was congested in 








1 



DYSMENORRHEA. 103 

This tabular testimony of 129 cases is a strong argument in 
favor of Dr. Sims's theory that dysmenorrhoea is almost always 
caused by obstruction. 

The inflammatory variety is attended with every grade of suf- 
fering, from a very moderate amount of pain to the intensest 
agony. The pain may, and, I think, usually does, begin before 
the beginning of the flow, and subsides after the discharge be- 
comes well established ; or it may begin at the time of the begin- 
ning, and last during the whole flow ; or it may not begin until 
after the discharge becomes free, and then cease with it; or, again, 
the pain may come on with the cessation of the flow. I have seen 
instances in which the blood made its appearance, and continued 
for two or three days, and then ceased without pain ; and in a day 
or two the flow was re-established with very great suffering. In 
inflammatory cases the pain is not uniform in character ; some- 
times it is constant and aching in the region of the uterus, or ova- 
ria, or both ; sometimes cramping, and compared to colic, with in- 
tervals of ease, and again of a terrible tenesmic character. The 
cramping and tenesmic pains would indicate obstruction, if any 
kind of pain would ; but in many of these cases there is an en- 
larged, instead of a contracted, state of the cervical canal, and 
upper and lower os uteri. It is often attended with chilliness, fol- 
lowed by reaction. I think, also, there is no foundation for the 
opinion that simple displacements cause dysmenorrhoea. 

The neuralgic dysmenorrhoea described by authors, but of which 
I have seen so little that I cannot speak authoritatively, occurs in 
patients subject to neuralgic attacks elsewhere, as in the head, 
face, &c. Instances that seemed to me to be more nearly like it 
than others I have found to be attended with some endocervicitis, 
or endometritis, and to yield to local treatment alone. I do not 
remember ever to have seen the attempt made to cure these cases 
by local management fail. It is true that this trial has been made 
either under my own immediate attention or by my instruction. 

And I wish to be specific in my statement that there were many 
of them just the kind of cases described by Dr. West, in his admi- 
rable work on females, as neuralgic. My own observation drives 
me to the conclusion, therefore, that many of the cases, described 
as neuralgic dysmenorrhoea are at least attended by inflammation 
of the mucous membrane of the cervix or body of the uterus, and 



104 MENSTRUATION AND ITS DISORDERS. 

that the cure of this inflammation cures the dysmenorrhea. But 
I am also thoroughly convinced that a neuralgic diathesis exists 
in many of the patients, thus aggravating the suffering in particu- 
lar instances. If neuralgia was the essential nature of these cases, 
my treatment ought not to have cured them. I am inclined to 
think that the uterine inflammation causes the neuralgic diathesis 
in these cases. I am sure that although I have tried such reme- 
dies as were suggested by my reading and observation in neuralgic 
diseases, yet I have invariably failed with every kind of treatment, 
besides that of local applications to the diseased mucous membrane. 
It may be that I am wrong, but I regard the treatment as the pro- 
per diagnostic means when made use of in this way. I wish here 
to say that I hope no one will underestimate my respect for the 
fathers or masters in the profession. I have followed them with 
becoming veneration, and shall continue to do so ; but I cannot 
always arrive at the same conclusions they do, and I must respect- 
fully ask to enjoy the independence I am forced to assume by my 
own observation, and request correction from my compeers after 
they have reviewed the facts upon which my opinions are based. 
Although I have, in my division of the subject, enumerated neu- 
ralgia as a variety of dysmenorrhoea, out of veneration for author- 
ity, I believe that the nervous is the unimportant element instead 
of the essential one. 

The membranous variety of dysmenorrhoea is more rare than 
the others. Whether inflammation has anything to do with the 
process of formation of this membrane, I am unable to decide. 
There is one thing I can say, however, and that is, that this con- 
dition is often associated with it. I am not disposed to discuss 
the question as to the formation of a delicate membrane during 
each act of menstruation, or the sameness of this dysmenorrhoeal 
production with that of the deciduous membrane of pregnancy. 
It undoubtedly is the result of disease in the cavity of the corpus 
uteri. In all the cases I have had an opportunity of thoroughly 
examining, there was very considerable disease of the submucous 
or fibrous tissues of the uterus. I do not wish to be understood 
as arguing that inflammation is the cause of this membrane, for I 
am not prepared to do so. Indeed, I think the subject has not 
been sufficiently investigated by anybody to decide. The struc- 
ture of the membrane appears identical with that of an early de- 



DYSMENORRHEA. 105 

cidua. If it is so, it is interesting to inquire how this identity with 
pregnancy can be produced. The symptoms in this sort of dys- 
menorrhoea are generally quite intense, and the patients suffer 
longer than usual. If there is any difference in the character of 
the pain in this class of cases as distinguishing it from others, it 
is more expulsive, and resembling more nearly the throes of labor. 

The diagnosis between the different varieties of dysmenorrhea 
cannot otherwise be complete but by examining the discharges for 
the membrane, and making a thorough physical examination of all 
the pelvic organs. I need not stop to give the different steps of 
such examination. When there is obscurity, the rectum, bladder, 
ovaria, and urethra, should be carefully scrutinized. In most 
cases there will be found evidence of some form of disease of some 
of these organs. The detection of the membrane will of course 
determine to which division it belongs in a very clear manner. 
The only danger of mistake is between the membrane of early 
abortion and that of dysmenorrhoea. Abortion at the menstrual 
period only occurs occasionally, and the intervening "periods" are 
free from pain or the discharge of the membrane. In dysmenor- 
rhoea the recurrence is regular at each menstrual time. The ap- 
pearances of the membrane are not such as to warrant a decision 
based upon them alone, in all cases at least. 

Prognosis. — The inflammatory form may be cured with a good 
deal of certainty by local treatment for that condition of the 
uterus. The membranous form is very difficult of cure, and can 
seldom be accomplished with the ordinary mode of treatment. 

Treatment.— The urgency of suffering in many cases of dys- 
menorrhoea calls for very energetic palliative treatment. We can, 
therefore, with great propriety divide the treatment into palliative 
and radical, or curative. The former, intended merely to palliate 
the sufferings during and between the paroxysms ; the latter, to 
prevent the return of them, by removing the conditions upon which 
they depend. When there is a strong element of inflammation in 
the case, the palliative measures must be derivative and antiphlo- 
gistic as well as anaesthetic. A vapor bath taken at the beginning 
of the paroxysm, sufficient to induce copious perspiration, is often 
attended with great relief. A brisk saline cathartic a few hours 
before the supervention of the great agony, will generally modify 
its asperity. Cupping to the loins, hot hip-baths, and general hot 



106 MENSTRUATION AND ITS DISORDERS. 

baths, are all sometimes very beneficial. I have been in the habit 
of treating the cases attended with endometritis, with first a dose 
of Rochelle salts the day before the paroxysm, dry cupping to the 
loins upon the supervention of the first symptoms, to be immedi- 
ately followed by from ten to twenty grains of Dover's powder, 
and a vapor bath. Soon as copious diaphoresis is fairly brought 
about, the patient should be wrapped up in blankets and put to bed. 
If the pain becomes intense, notwithstanding these means, the pa- 
tient may be kept under the influence of sul. ether until quiet sleep 
is induced. If there is no obvious inflammation, the opiate of Do- 
ver's powder or morphia, followed by ether or chloroform, will do, 
witbout the bath or cupping. Dr. Simpson uses the chloroform 
in the beginning of the paroxysm with great confidence, but does 
not expect this anaesthetic to interrupt the paroxysm unless given 
at the very beginning. I think, given at the time of the adminis- 
tration of opium, it renders the operation of this drug more prompt, 
while the opium prolongs the effect of the chloroform. Usually, 
they certainly act very pleasantly together. Various local anaes- 
thetics are recommended and used. The carbonic acid gas, car- 
ried from a generating apparatus through a tube into the vagina 
in a full stream a considerable time, obtunds the sensibilities of 
the parts, and thus relieves the pain. Chloroform can also be used 
in the same way. Opium, belladonna, hyoscyamus, aconite, and 
other remedies of this class, used as suppositories, may very prop- 
erly be resorted to under certain circumstances. From the ob- 
servation of the fact of the simultaneous irruption of the menses 
and subsidence of the pain, the patients are apt to resort to the 
use of strong stimulants, which have the reputation among them 
of promoting the flow. This practice should be discouraged, as 
having, in the end, generally an injurious effect. Antiphlogistics, 
anodynes, revellents, and anaesthetics, are more rational and al- 
most always more beneficial. The paroxysm of the membranous 
variety calls, in addition to some or all the above-mentioned reme- 
dies, for another important item of treatment. The more readily 
the membrane can be expelled the sooner the suffering is ended. 
I have now used on several occasions the ergot, with, as it has 
seemed to me, very great advantage, shortening the paroxysm by 
many hours, without increasing the painfulness of the paroxysm at 
all. Under the influence of large and frequently repeated doses, 



DYSMENORRHEA. 107 

as grs. xx, every half hour for two or three hours, I have many 
times known the membrane expelled apparently very much sooner 
than it otherwise would have been done, judging from the course 
of former paroxysms. And what seemed curious, the pains were 
much more tolerable while the patient was ergotized. Sometimes 
ergot fails to have any effect, as it does under other circumstances. 

The radical treatment of dysmenorrhea is attempted by general 
remedial measures, or by local treatment of the uterus or other or- 
gans diseased, for the purpose of removing their morbid condition. 
As has been already remarked, dysmenorrhea is sometimes at- 
tended, if not produced, by certain diathetic conditions. Rheuma- 
tism, gout and scrofula are all blamed for it in some instances, 
where the patient is evidently laboring under any one of these 
general states. And it is very correct to make use of general means 
to correct them, with a view to the cure of the dysmenorrhea. 
Tinct. guaiac. ammon., given as directed by Prof. Dewees, in 5j 
doses, three times a day for a long time, is sometimes curative and 
often palliative in its effects. Colchicum does much good in rheu- 
matic patients, and the terebinthinates in various forms are popu- 
lar remedies. When the patient's health indicates a marked scrofu- 
lous condition, cod-liver oil, and iodide of potassium, iodide of iron, 
and much outdoor exercise, with generous meat diet, warm cloth- 
ing, and regulated bowels, are essential. In all cases, we should 
carefully study the condition of the health, and diligently endeavor 
to correct any deviation we may discover. I have seen several re- 
markable cures by thus attending, for a reasonable length of time 
(several months), to the general health alone. Sometimes a gentle 
salivation, connected with a course of tonics, does a great deal of 
good. I have sometimes administered §ss. of compound tinct. 
cinch, with the twentieth of a grain of the bichl. hyd. three times 
a day after eating, for this purpose, with great benefit. 

Very frequently a large majority of the cases are connected 
with inflammation in the pelvic organs, or some one of them. 
When this is the case, our treatment may be general or local, or 
both combined, according to the organ affected. If there is evi- 
dent inflammation of the ovaria, leeching, cupping, counter-irrita- 
tion, and the alterative effects of mercury, very gradually induced, 
followed or accompanied with tonics, is the advisable course to be 
pursued. Leeches or cupping just before the menstrual period is 



108 MENSTRUATION AND ITS DISORDERS. 

the best time for their use, applied over the ovary that seems to be 
affected, or persistent counter-irritation by means of a seton, kept 
open for months. Of all the organs in a state of inflammation 
causing dysmenorrhea, however, the uterus is very much the most 
frequently thus affected. And the form is generally that of endo- 
metritis, or endocervicitis. 

I wish to discuss here the effects of some remedies that have 
cured this affection when used for other purposes, — to dilate a 
stricture, for instance. Since I have made these diseases some- 
what a special study, I have had occasion to try the effects of dila- 
tation by means of bougies, stem pessaries, and prepared sponge, 
and have found much good to result from all of them. But there 
is one thing I have learned of the use of these instruments that 
has not been mentioned by those who have heretofore recom- 
mended them, and that is, that they will do just as much good in 
many cases when there is no stricture as where there is. I have 
used the bougie as recommended by Dr. Mcintosh, and the stem 
pessary according to Dr. Simpson, when the cervical canal was 
open more than naturally, with as much good effect as when the 
canal was very narrow. The explanation of all this is, that these 
means modify at first and finally cure the endocervicitis, upon 
which the dysmenorrhoea depends, and in this wise relieve the pa- 
tient. The dilatation by the uterotome of Dr. Simpson, making- 
free incisions, cures the cases, not by merely giving freedom of 
discharge to the pent-up blood, but by their effect upon the inflam- 
mation. It is rather emptying the capillaries of the part inflamed, 
than the cavity of the uterus, that effects the cure. 

It is my conviction that mucous or submucous inflammation, or 
both, is generally the cause of the narrowing of the cervical canal, 
and the sufferings of the patient. 

I do not consider the above-mentioned modes of treatment the 
best in such cases, although they do sometimes effect cures, and 
would refer the reader to the treatment of inflammation of the 
cervix in another part of this work. A few applications of the 
solid caustic to the mucous membrane so modifies the disease, that 
in many instances the first paroxysm after the commencement of 
them is attended with very much less suffering. Generally the 
improvement is gradual, however, but progressive as the inflam- 
mation subsides. 



DYSMENORRHEA. 109 

Whatever the condition of the lining membrane of the uterus 
may be, in the membranous variety of dysmenorrhea, the object 
of treatment is to change it from the morbid state. I am not sure 
that there is ordinarily a state of inflammation. The morbid state 
may be removed sometimes by a long course of alterative treat- 
ment of a general character. But I cannot now recall a case in 
which I have been fortunate enough to succeed thus. These cases 
are very difficult to manage, and obstinate under the best treat- 
ment. The successful plan, in my practice, consists of applica- 
tions made directly to the mucous membrane of the uterus, by 
introducing lunar caustic, acid nitrate of mercury, or tinct. ferri. 
chl. into the cavity. I have on several occasions — seven in all — 
thus cured it. In three of the cases it became necessary to dilate 
the cervix with a sponge, so as to make application freely. I di- 
lated the cervix a week or ten days before the expected paroxysm, 
so that the finger could have been introduced, and through the di- 
lated cervical cavity, by means of a piece of cotton on whale- 
bone, made a thorough application of the acid nitrate of mercury 
to the mucous membrane of the cavity of the uterus. I have seen 
no disagreeable results from this treatment, and shall feel justified 
in again resorting to it when the urgency of the case demands it. 
Three of such applications as this were all that was required. In 
the other four instances the nitrate of silver was used by means of 
the flexible caustic-holder, alternated with the tinct. of iron, with 
the cotton swab. It required six months in one, and in the others 
from eight to eighteen months. The general treatment must be 
governed by the general condition of the patient to a great degree. 
If she is weak -and debilitated, tonics, a generous diet, exercise in 
the open air, good company, and ease of mind, are indispensable 
in connection with alterative medicines. Continued use of sitz 
baths for months together will relieve the irritability very much 
sometimes. But I would urge efficient applications of the medi- 
cines above-mentioned to the uterine mucous membrane, as the 
most likely to cure this very obstinate and painful affection. Make 
the applications thorough if possible through the cervical canal in 
its natural condition, but if too narrow for this purpose, dilate it, 
and after dilatation, make the application thorough. And I think 
for this purpose the acid nitrate of mercury the best. These ap- 
plications must be repeated until the cure is accomplished. The 



110 



MENSTRUATION AND ITS DISORDERS. 



acid nitrate of mercury may be used once a month, or the nitrate 
silver once a week. 

As I have given the opinion of Dr. Sims as to the causes of dys- 
menorrhea, I cannot complete this article without giving the 
reader an idea of the mode of treatment found most successful 
by him, viz., that of dilating and strengthening the canal of the 
cervix. He exposes the mouth of the uterus by placing the pa- 
tient in the same position, and using the same instrument as for 
vesico-vaginal fistula. With a tenaculum he seizes and firmly 
holds the cervix and draws it into the most convenient position.. 
If the cervix is not flexed but merely narrow, he introduces one 
blade of the scissors into the canal of the cervix far enough to di- 
vide it on one side up to the junction with the vagina, and then 
closes them. The other side of the cervix is divided to the same 
extent in like manner, then, by means of the knife represented in 
figure, he divides the cervix up as high as the internal os. 

Fig. 13. 




Fig. 13 represents the operation for dividing the straight cervix when too narrow. The dark part 
the portion cut. On one side the knife is shown in the act of dividing the tissues. This is Dr. 
Sims's plan. 



DYSMENORRHEA. 
Fig. 14. 



Ill 




Emmet's Knife for dividing cervix. From a cut in the June Number, 1864, New York Journal 

of Medicine. 

If the cervix is flexed, the lip of the uterus on the convex side 
is divided to the same height, and then the cervix opened with the 
knife. In this way the cervical canal is rendered rectilinear. 

This is represented by Fig. 15, taken from page 169 of Dr. 
Sims's new work on Uterine Surgery. It shows the posterior lip 
already divided by the scissors, the tenaculum fastened into the 
anterior lip, and the knife being inserted as high as necessary. 

Fis. 15. 




" The representation in the cut is taken from the perfected in- 
strument made by Wade & Ford, of New York city. To their 
ingenuity is due the application of the principle. The represen- 
tation is half the size of the instrument, but the blade at full size 
is out of proportion, as it should be represented both longer and 
narrower." 



112 MENSTRUATION AND ITS DISORDERS. 

After having thus completed the operation, Dr. Sims places in the 
wound of the lip of the cervix some cotton saturated with glycer- 
ine, and then proceeds to fill the vagina with cotton to guard 
against hemorrhage, which he regards as always imminent. If 
there be but slight bleeding, it is not necessary to use more cotton 
than will keep the dressing in place. The patient should keep 
the recumbent posture for several days. The cotton in the vagina 
may be removed in twenty-four hours after the operation ; that in 
the wound remains from two to three days. Dr. Emmet recommends 
that the sound be passed through the cervix every other day until 
the discharge ceases to prevent the parts from adhering. The 
sound need not be used for this purpose until the tampon is dis- 
pensed with. 

In the American Journal of Medical Science for January, 1867, 
I find the following summary, which I present to the reader with- 
out apology: 

" Comparative Merits of Incision and Dilatation of the Mouth 
of the Womb in cases of Dysmenorrhoea — Professor D. Humph- 
reys Storer read, in August last, a highly interesting paper on 
this subject before the Boston Society of Medical Improvement. 
The large experience and sound judgment of Professor Storer not 
only entitle his opinions to a respectful consideration, but his con- 
clusions to entire confidence. He says : ' From a somewhat ex- 
tensive employment of sponge-tents during the ten past years for 
the treatment of dysmenorrhoea and sterility, I have formed con- 
clusions different from those of the gentlemen of whom I have spo- 
ken (Drs. Barnes, Baker Brown, Greenhalgh, and Sims). I have 
not unfrequently been disappointed in the result hoped for. The 
local obstruction has almost always been overcome by the long- 
continued, persevering employment of the dilator ; but the opened 
canal does not always remove the condition thought to depend 
upon its closure, — dysmenorrhoea and sterility still remain. I 
have, however, never seen the ill effects spoken of from the em- 
ployment of tents. I cannot recall a single instance where more 
than a few hours' inconvenience has been produced ; and in such 
cases the expanded sponge, when removed, has proved to have 
been originally much larger than it was supposed to be — showing 
that he who employs these tents should be acquainted with their 
uncompressed dimensions. My experience has taught me, then, 



DYSMENORRHEA. 113 

that these contractions, however firm they may be,. may almost in- 
variably be overcome. The physician need not feel that the part 
is undilatable because the application of three, or five, or half a 
dozen tents does not overcome it; in a case occurring in my prac- 
tice, about a year since, eighteen sponge-tents were introduced at 
intervals of two and three days before the canal was opened. My 
perseverance was rewarded by the perfect relief of the patient. I 
could point, were it necessary, to several cases where, after years 
of sterility, the sufferer has been relieved and borne children, and 
in the intervals of their childbearing have suffered no dysmenor- 
rhcea. I have repeatedly seen cases of dysmenorrhcea remain re- 
lieved for years, and known no return. In a word, I have relied 
upon dilatation to relieve these affections, and whatever opinions 
may be advanced by others, so long as I feel we have a remedy 
from which we can confidently expect relief, and very rarely ob- 
serve any injurious effects, I shall feel it my duty to employ it. 

" That cases do occur where the difficulty cannot be removed by 
dilatation, there can be no question ; but i that incision is the only 
efficient and permanent remedy (in most cases) for dysmenorrhcea,' 
I unhesitatingly deny. 

" Let us for a moment look at the method proposed. Those 
who advocate it should of course be satisfied that it has superior 
claims over the means now employed. I have thought the ill ef- 
fects produced by distension might be occasioned by want of care ; 
but those arising from incision may follow the operation of the 
most skilful surgeon who advises it, when the metrotome cuts 
through the walls of the inner os ; and Dr. Barnes states, to em- 
ploy his own language, ' there is no doubt that the surgeon has 
actually cut through the substance of the uterus, and wounded 
the plexus of vessels outside ; hence severe and dangerous hem- 
orrhage has ensued, and inflammation of the peri-uterine tissues.' 
And even supposing the operation should be successfully per- 
formed, it is acknowledged by Dr. Routh, one of its advocates, 'that 
such an amount of contraction frequently exists as to render it nec- 
essary to have a dilating substance worn for a considerable length 
of time to prevent its perfect occlusion ;' and Dr. Williams observes 
that « oftentimes no relief is afforded. He had seen a patient whose 
cervix uteri had been slit up on both sides, forming two large pro- 
truding lips, without affording any relief to the sufferer.' Where 

8 



114 MENSTRUATION AND ITS DISORDERS. 

the external os has been almost cartilaginous to the feel, I have 
overcome the obstruction with the hysterotome ; but I have never 
attempted to divide the internal os. I cannot, however, recall the 
instance where it was required." — Boston Medical and Surgical 
Journal, September 2, 1866. 



CHAPTER VIII. 

METATITHMENIA (MsraTid^fa firjv) ; OR, MISPLACED 
MENSTRUATION. 

The accident to which I apply the above term is called retro- 
uterine hematoma, peri-uterine hematoma, and uterine hemato- 
cele. This nomenclature has reference to the effusion of blood 
near the uterus, without reference to the time or mode of occur- 
rence ; while the appellation I employ takes into consideration at 
once the cause and the fact of sanguineous effusion, which occurs at 
the time, and, generally, in consequence of menstrual congestion. 

As will be gathered from what I have already said, it is an effu- 
sion of blood in tissues around and above the uterus ; the effusion 
being sometimes very extensive, at others limited to a small space. 
The effusion may take place in the vaginal wall, between the vagina 
and rectum, tearing up their connecting tissue; or the posterior 
wall of the uterus, beneath the peritoneum ; between the perito- 
neal layers of the broad ligament beside the uterus, or in the 
peritoneal cavity. The mode of the accident varies somewhat, 
owing to the locality in which this blood is found. The blood is 
effused in interspaces beneath the peritoneum and elsewhere, as the 
effect of a rupture of some vessel ; but while effusion may be, and, 
perhaps, generally is, attended with a ruptured vessel in the peri- 
toneal cavity, the blood sometimes also arrives in that cavity from 
the uterus through the Fallopian tubes. We are not yet able to 
decide which of these circumstances is the more common. 

The time of menstruation, or shortly before or after, is the time 
when this accident happens ; and it may fairly be considered as a 
result of menstrual congestion, or effusion. As an accompaniment 
of menstrual congestion, the bloodvessels of the whole genital 
organs are greatly distended, and in certain cases this turgidity 
becomes too great for their capacity, and a rupture is caused at 
some particular place ; or, the cavity of the uterus being filled 
with a profuse flow into it, the blood regurgitates through the 



116 MENSTRUATION AND ITS DISORDERS. 

tubes into the peritoneum. It is not likely, however, that any 
considerable effusions are thus caused ; so that the sudden and 
copious collections sometimes observed, must be accounted for 
upon the supposition that a small arterial twig has given way in 
the ruptured ovisac at the time of the escape of the ovum, and 
poured the fluid rapidly into the sac formed behind the uterus by 
the descent of the peritoneum. I think the instances I have wit- 
nessed were more frequently connected with cases of disordered 
menstruation ; but I have also seen it take place in patients whose 
menses were normal, so far as I could determine. 

Dysmenorrhea may be regarded as the most common deviation 
accompanying misplaced menstruation. 

There can be no doubt but that effusions of blood, in every re- 
spect similar to misplaced menstruation, are caused by the condi- 
tion of the uterus and appendages in abortion, and even after 
labor ; but when so, the modus in quo is precisely the same, the 
congestion being caused, not by the menstrual molimen, but by the 
congestion of pregnancy and morbid excitement which sometimes 
attend these two states, — rupture of a small vessel, or regurgita- 
tion, being the immediate condition. 

Sanguineous collections arising in this way may be minute in 
size, but sometimes the quantity of blood is dangerously, and even 
fatally, large. The small collections are forced into places where 
distension is most difficult, as in the cellular tissue, while the large 
effusions are met with in the peritoneal cavity. Immediately after 
the blood is extravasated, changes begin to take place in it, and 
the tissues occupied by it. Inflammation, to a greater or less de- 
gree, almost always is the result. In a mild grade, the inflamma- 
tion produces an effusion of serum which augments the bulk of the 
accumulation, and makes the appearance of much blood, when in 
reality there is but a small quantity. When this is the state of 
things, the disappearance of the tumor, by absorption, may be ex- 
pected in a comparatively short time. And we often see it re- 
moved by absorption in a very few weeks. 

The intensity of the inflammation is frequently much greater, 
proceeding through the stage of serous effusion to the production 
of fibrinous deposit. A hard tumor is the result. This again may 
remain for a longer or shorter time permanent, and then very 
slowly disappear, or only be partially taken away, leaving a per- 



MBTATITHMBNIA. 117 

manent hardness ; or, what is not unfrequently the case, proceed 
to suppuration and discharge in some way or other. 

I have seen as many as two cases terminate fatally by the ex- 
haustion of suppurative fever, without the discharge of the con- 
tents of the tumor. When suppuration is fairly established by 
the inflammation thus arising, exulceration and evacuation follow 
as a general rule. The vagina is more frequently perforated by the 
ulcerative process, but the rectum, bladder, or uterus, may serve as 
the conduit of discharge. If the inflammation is of an acute char- 
acter, and the steps in the process of evacuation rapidly succeed 
each other, the character of the discharge will partake largely of 
a bloody quality; but should the time required by exulceration be 
considerable, pus will prevail in the composition. In any case, 
however, the discharge is a mixture of pus and changed blood. 
This last is sometimes very greatly changed, but in others but 
slightly. In rare instances, the peritoneum is inundated by rup- 
ture into its cavity with this mixture of pus and blood, and over- 
whelmed with a general inflaiiimation, soon resulting in death. I 
have seen two cases of this kind, which were verified by post- 
mortem appearances. 

After absorption in the cases attended with the milder grade of 
inflammation, very slight traces of it, if any, can be found by ex- 
amination of the patient. When effusion of fibrine takes place, 
displacements, permanent adhesions of the uterus and other parts, 
and deformity, will be left behind, considerable or slight, as the 
amount of deposit was small or great. These changes will, of 
course, be greater after the process of suppuration and discharge 
has been reached by the inflammation. Fistulous and tortuous 
openings may also embarrass the convalescence of the patient, or 
even by their long continuance exhaust her. 

Symptoms. — The symptoms of metatithmenia vary in different 
instances. The attack is generally sudden and well marked. At 
the time, just before or after the menses are flowing, the patient is 
seized with severe pain in the hypogastrium or one of the iliac 
regions. Frequently there is also a sense of faintness, sometimes 
slight, but often it amounts to complete syncope. In place of the 
faintness there are sometimes coldness and tremors. The pain 
becomes persistent, and, perhaps, less severe, but not unfrequently 
it increases for a considerable time and then gradually diminishes. 



118 MENSTRUATION AND ITS DISORDERS. 

After the inception the pain usually spreads over the abdomen to 
the back and hips,. and sometimes down the thigh and leg. As 
the pain becomes greater or extends over a greater space, febrile 
reaction is developed, generally moderate in grade, but occasionally 
the reaction is excessive ; the pulse becomes rapid, the heat con- 
siderable, and the patient complains of great depression and thirst. 
The abdomen increases in size and becomes tympanitic, while there 
may be a distinct tumidity and hardness felt in one of the iliac 
regions ; sometimes the hardness extends over the hypogastric to 
the other ilium. This hardness and swelling may scarcely rise 
above the pelvic brim, but it not unfrequently is perceived extend- 
ing as high as the umbilicus. It is not much, if at all, tender to 
the touch. It is irregular in its outline also. In very rare in- 
stances the effusion takes place slowly, the symptoms are devel- 
oped quite gradually, and the time of the beginning not so defi- 
nite, but the subsequent course of them are apt to be the same. 

After the symptoms are fully manifested they pursue a course 
corresponding to the grade of inflammation which is awakened by 
the effusion. In some cases the inflammation around the effusion 
is active and intense, and continues with severity until suppuration 
and exulceration end the process. 

Of course the fever is corresponding in grade and persistence, 
passing through the high grade to hectic, attended with all its ex- 
hausting discharges. If the inflammation is less acute, the fever 
may be persistent for weeks, and sometimes for months, but of more 
moderate grade, until it gradually subsides, or slowly ends in 
suppuration and discharge. Fortunately, in the large majority of 
cases, the amount of the effusion is small, the grade of inflamma- 
tion slight, and the duration but a few days or weeks. 

Subsidence of an attack of metatithmenia and recovery from it 
are not generally followed by a series of them. But there are two 
ways in which individuals are rendered miserable by its frequent 
recurrence. One is, when all the symptoms subside entirely for 
months, and then return. The tumor entirely disappears, the in- 
flammation is wholly gone, and the patient feels that she has fully 
recovered her health, when, suddenly, during a menstrual flow, she 
is again seized with pain, swelling, fever, &c, which again subsides 
to be repeated more or less frequently. I have a patient who has 
suffered attacks of this sort perhaps twenty times in the last six or 



METATITHMENIA. 119 

seven years, in whom the tumor has at different times been mis- 
taken for ovarian or uterine tumors. In the other way, the sub- 
sidence is only partial : there is all the time some tumidity, some 
inflammation, and more or less sympathetic suffering, with occa- 
sional severe returns. More blood is effused, the tumor is in- 
creased in size, and the inflammation intensified, and all subside 
to a partial extent and again return. When the tumor is much 
inflamed and suppurates, it may suddenly discharge through the 
vagina; all the urgent symptoms readily subside, and the patient 
becomes convalescent. Again, the discharge is sometimes slow 
and difficult, the relief is imperfect, and a protracted convalescence 
the result. But sometimes, after a course corresponding to the 
above description, sudden and general peritonitis is lighted up by 
extension of inflammation from the sac, or a discharge of some of 
its contents into the peritoneal cavity. The discharge is generally 
fetid and highly irritating, consisting of partially decomposed 
blood, pus, and ichor. It is always offensive compared to dis- 
charges from an ordinary abscess. I have seen one or two in- 
stances in which the general symptoms were not manifested at all, 
nor did the pain amount to anything more than an inconvenience, 
not very difficult to bear. It is interesting to observe the effects 
of this misplaced menstruation upon the flow per vias naturales. 
Occasionally no effect seems to be produced, the flow being natural 
in quantity and duration ; in fact, it is just at the time of the ces- 
sation of the discharge that effusion into the tissues takes place, 
but at other times there continues for many weeks a constant 
stillicidium of 'blood. Or, occasionally, — when they occur during 
the course of the symptoms. — the amount of menstrual discharge 
is very much increased. I knew one patient that had a constant 
slight sanguineous discharge from the vagina for six months, and 
at the regular menstrual periods copious hemorrhages. In other 
cases they are more scanty than usual. 

Diagnosis. — There are several conditions with which it may be 
confounded, if some caution is not observed. Inflammation of 
pelvic cellular tissue, or pelvic abscess, is the one most likely to 
be mistaken for metatithmenia, or this last for the first. And as 
I have already shown, the abscess is sometimes the result of mis- 
placed menstruation, the effusion in the tissues exciting intense 
inflammation, which proceeds to the stage of suppuration. It is 



120 MENSTRUATION AND ITS DISORDERS. 

not unlikely, indeed, that a larger number of these abscesses have 
a hemorrhagic nidus than we at present suspect. However this 
may be, we will often have reason to hesitate in our diagnosis. 
The inflammation in cellulitis is not ordinarily ushered in by the 
same suddenly occurring acute pain and faintness. Chilliness and 
fever are more marked from the beginning, the pain usually com- 
mencing after the fever has begun, or, at least, increasing after the 
fever is established. The tumor above the linea ilio-pectinea is 
not perceptible for many hours, oftener one or two days ; it is ex- 
tremely tender, and even in its outline. The tumor in metatith- 
menia is observed in a few hours, and is not so very tender to the 
touch. It may be handled and pressed upon much more freely 
than the tumor of simple inflammatory origin. If examined per 
vaginam the inflammatory hardness and swelling is very firm. It 
is usually lower down and more to one side. The tumor from 
sanguineous effusion is quite elastic at first, and presents an edge- 
like projection down behind the uterus, entirely below the os and 
cervix. The finger may be pushed up between the cervix and the 
tumor, and the thick convex edge of the latter reminds one of a 
thick cake. There is very little tenderness, and vessels may al- 
most always be felt pulsating over this projection. I need not say 
that this is never the case in the early stages of cellulitis. The 
vessels in this last are obliterated by fibrinous and serous effusion. 
If inflammation of a high grade speedily follows the effusion of 
blood in the tissues, the symptoms of the two may be so intimately 
blended as to make it doubtful how the tumor began, and, in fact, 
to convert it into pelvic abscess. Tumors of the uterus, under cer- 
tain circumstances, may be confounded with the tumor of san- 
guineous effusion ; but their firmness, the want of conformity to 
the shape usually assumed by this last, the enlargement of the 
uterine cavity, our ability to isolate them by the fingers and probe, 
their gradual, unperceived growth, and their mobility, will almost 
always suffice to make the distinction manifest. From ovarian 
tumors they may be distinguished by the more regular outline, 
fluctuation on percussion, less grave symptoms, gradual develop- 
ment, absence of the projecting edge behind the uterus, the want 
of the beating vessels, &c, in ovarian growths. Displacements of 
the uterus may always be made out with great certainty by intro- 
ducing the probe into its cavity to ascertain the direction of the 



METATITHMENIA. 121 

fundus, and correcting its deviations. Hence the diagnosis need 
not be long embarrassed by any question in reference to tkern. 
Retroversion of the impregnated uterus is constantly attended 
with great urinary distress, while metatithmenia seldom is. Ex- 
tra-uterine pregnancy, perhaps, in some instances, more nearly 
resembles it than any other, but the enlarged and flaccid cervix, 
open os, dark color, and enlarged cavity, in this sort of pregnancy, 
and their absence in the accident we are considering, will suffice to 
distinguish between them. 

Causes. — Anything that induces intense and prolonged con- 
gestion of the vessels of the ovary and uterus may, under cer- 
tain circumstances, produce effusion, by rupture of some of the 
minute ramifications. And there is reason also to believe, as 
shown by Dr. West, that when the os uteri "does not permit of 
easy flow from it, that the blood, after accumulating in the cavity 
during the menstrual effusion, may be passed out through the Fal- 
lopian tubes and escape into the peritoneal cavity." In what pro- 
portion of cases this takes place is not known. Both of these 
circumstances being present, congestion of the vessels of the uterus 
and ovaria, and effusion of blood in the cavity of the uterus at the 
time of menstruation, will explain why this last is considered the 
almost invariable causing condition. The whole etiology is not 
given, however, in the above explanation, and the balance finds its 
expression in "a peculiar susceptibility," or, in other words, it is 
not known why it should occur when it does, and why it does not 
take place at other times. 

Prognosis. — The dangers to be apprehended in metatithmenia 
arise, 1st, from the shock of the effusion in the peritoneal cavity, 
which, however, is not generally considerable ; 2d, fatal exhaus- 
tion from the amount of effusion in the abdominal cavity; and, 3d, 
inflammation and its effects. From inflammation we may fear 
death, permanent damage to the organs about the pelvis, and great 
suffering. Very few patients escape without protracted suffering, 
often weeks and sometimes months, from the inflammation lighted 
up by the effusion. 

Damage to a greater or less degree frequently follows the dis- 
placement, adhesions, perforations, and thickening of the uterus, 
vagina, rectum, and bladder. The exhaustion of protracted febrile 
excitement, perspiration, diarrhoea, and vigils, not very seldom 



122 MENSTRUATION AND ITS DISORDERS. 

wears out the vital resistance of the patient, often of a very deli- 
cate constitution ; or sudden and violent inflammation of the peri- 
toneum overwhelms and destroys her. The prognosis in any given 
case will be governed by the intensity of the symptoms, and the 
comparative strength of the patient. If the amount of the effusion 
be never so large, and there be but little inflammation, the prog- 
nosis is more favorable than if the effusion be small and the in- 
flammation great. In fact, I think we may with great propriety 
form our prognosis by the amount and intensity of the inflamma- 
tion alone, as it is almost the only source of danger. 

The proportion of deaths compared to recoveries perhaps will 
range not far from ten per cent. This at least is the result of my 
observation and research up to the present time. 

As before observed, a cause of death, though not frequent, 
should nevertheless be mentioned as influencing the general sub- 
ject of prognosis in misplaced menstruation, viz., a fatal amount 
of extravasation of blood in the peritoneal cavity. More than one 
case is recorded in which there was fatal prostration, coming on 
and pursuing its course in a few hours, which, when examined, re- 
vealed as the source of an extensive and copious hemorrhage, a 
ruptured twig of artery on the ovaria. Of the many cases that 
come within our observation, the number that thus prove fatal are 
extremely few. 

Treatment. — The three great facts of this accident, — hemor- 
rhage, pain, and inflammation, — afford us indications for treat- 
ment sufficiently plain to guide it correctly. It is very seldom 
that we are sent for, or in any way see these cases, until after the 
hemorrhage has exhausted itself or been stopped by backward 
pressure, after filling up the space into which the bleeding takes 
place. Should we, however, meet with an instance during the hem- 
orrhagic stage, it would be very proper to make use of ice to the 
pelvic region, perfect quiet, and astringents internally, until the 
effusion ceased ; but, as I said before, such opportunities seldom 
offer themselves. The cases as we ordinarily see them, have pro- 
ceeded through this stage ; the effusion, in fact, is generally accom- 
plished in a few moments, or at most, very few hours. When we 
see the patient, she is either suffering with pain and prostration or 
coldness, the primary effects of the hemorrhage ; or pain, fever, 
and inflammation, and our treatment will be conducted according 



METATITHMENIA. 123 

to the conditions in these respects. Our resources in the first con- 
dition Trill lie in the use of opium or other anodyne, to relieve the 
pain as much as may be necessary, and if the prostration or chilli- 
ness is considerable, to stimulate sufficiently to establish equilib- 
rium in the circulation, but not febrile reaction. In very many 
cases it will be sufficient to keep our patient quiet, and place her 
upon moderate anodyne treatment, good nourishing diet, and per- 
haps after the first week or two, tonics, and she will slowly rally 
from the first shock, absorption of the blood result, and she soon 
will recover her health. In these moderate cases we cannot be too 
careful not to overdo the treatment. The patients will generally 
recover spontaneously in a few days or weeks. 

But another class of cases occur, as I have already said, in 
which inflammation very soon succeeds the sanguineous effusion. 
A knowledge of the mischief which this inflammation brings about 
should make us prompt in meeting it with appropriate remedies. 
If the inflammation runs high, adequate antiphlogistic measures 
will be indispensable to a favorable course. An active cathartic 
of calomel and jalap or some other alterative cathartic should begin 
at once, while at the same time, if deemed advisable on account of 
the force of reaction, we may apply a dozen or twenty leeches. 
These may be followed by the tinct. of veratrum viride, in doses of 
two drops every hour, until the pulse is brought down to its natural 
frequency and volume, if not below these conditions, and then con- 
tinue its use in less doses, or less frequently repeated, for some 
time. According to my observations, the most of adults will be 
affected to this point by taking as much as one drop an hour ; 
some will require more and some less. The energy of this anti- 
phlogistic course must be graduated by the force of inflammation; 
but few cases will require as much as is described here. Should 
the inflammation advance to suppuration, the remedies required 
will be supporting ; at first, sul. acid and quinine, and afterwards,, 
these with wine or other stimulants, nourishing diet, &c. These 
cases are often so protracted,, the patients are so much prostrated ? 
and suffer so much pain, that great skill will be called for to adapt 
the anodynes, tonics, and nutrients to the various conditions of the 
patient for so long a time. 

A question associated with the progress of inflammation, and 
one of great importance, is the propriety of evacuating the fluid, 



124 MENSTRUATION AND ITS DISORDERS. 

To evacuate the blood soon after its extravasation would seem to 
remove the cause of inflammation, and thus avoid it. To say that 
an early evacuation of the effusion would never be proper, is 
perhaps to assume an extreme position, and there may be cases 
where such evacuation is advisable, but I think the number re- 
quiring it must be very few, and I do not know any circumstance 
which would induce me to do it. Indeed, I should fear inflamma- 
tion, from the sudden discharge of a large amount of blood from 
the cavity, almost as much as if it were allowed to remain in it. 
There is another condition in which an operation for discharge of 
the contents of the tumescence is less a question of doubt, viz., 
when pus has become mixed with the blood, on account of inflam- 
mation. It is very important in some instances to puncture and 
discharge the fluid. When the patient is being worn out by the 
protracted course of the disease, and the perspirations and diar- 
rhoea which so often attend it, we must interfere surgically for her 
relief. And again, when the fluid is increasing, and the tumor 
rising in the abdominal cavity, without showing any disposition to 
" point " in the pelvis, or any other place where it is desirable to 
have it do so, there is danger of the discharge of the pus and blood 
in the peritoneal cavity, by rupturing the sac above, and we must 
anticipate it by choosing the place and mode. When we have de- 
termined to relieve the distension by puncture, we ought to use an 
exploring needle or trocar to ascertain the contents before evac- 
uating them. After being satisfied by this corroboration of our 
diagnosis, we may plunge a large trocar or even a knife into the 
most dependent part of the tumor. This point will almost inva- 
riably be immediately behind the uterus, but occasionally it will 
be at the side of the pelvis. 

After free puncture, either with the trocar or knife, the dis- 
charge readily takes place, and the patient immediately experiences 
great relief. If the puncture is made to remove the blood before 
inflammation has begun, the evacuation may be more difficult, as 
it is often coagulated ; in that case the opening must be made large 
with a knife, and if the blood does not easily flow, the finger may 
be introduced to break up the clots and facilitate their expulsion. 
After the contents are thus expelled as near as can be, they some- 
times reaccumulate and are again discharged, and repetitions of 
these processes lead to still more chronic suffering, until the patient 



METATITHMENIA. 125 

becomes a permanent invalid or dies from the exhaustion of such 
long standing. We may, with a good deal of certainty, cause con- 
traction, granulation, and obliteration of the cavity, by injecting 
it with iodine, wine, or other irritant. The best way to secure 
efficiency in injections is to introduce through the fistulous open- 
ing, or one made for the purpose, a small flexible catheter, so as 
to reach the bottom of the cavity, and throw the fluid through this 
tube. We thus place the fluid used in full strength in contact with 
the walls of the cavity, while the injection thrown out of a com- 
mon syringe will mix it up with the contents of the sac, and thus 
dilute it. 



CHAPTER IX. 

ACUTE INFLAMMATION OE THE UNIMPEEGNATED UTEKUS. 

Acute inflammation, not arising from specific causes, generally 
affects the fibrous portion or substance of the walls of the uterus. 
It almost, if not quite always, pervades the whole of the organ, 
the fundus, body, and cervix. The whole organ is inflamed and 
tender. Exposure to cold is the most frequent cause. The cold 
may be applied to the general surface when the uterus is in a state 
of turgescence from menstrual congestion, sexual excitement, or 
incomplete involution after labor or abortion. The same agent 
acting upon a portion of the surface, the feet and legs, under simi- 
lar condition of the organ, may give rise to the same disease. It 
is not likely that cold, however applied, would be a sufficient cause, 
but for the predisponent condition I have mentioned. The excite- 
ment of excessive sexual indulgence may be carried so far as to 
cause a moderately acute inflammation of the substance of the 
uterus, as also blows upon the abdomen, &c. 

It is not a very frequent disease, and yet I do not think it can 
be regarded as an unfrequent affection. 

Symptoms. — In speaking of the symptoms of the disease, I wish 
the reader to bear in mind that their intensity will vary from a 
mildness that will scarcely confine the patient to her couch to a 
very severe and grave disease, almost overwhelming the nervous 
system, with delirium and convulsions, and calling the stomach 
into excruciating sympathy with it. In considering the subject, I 
wish to be understood as attaching more importance to the sudden- 
ness than the intensity of the attack in determining the nomen- 
clature. 

It is somewhat owing to the exciting cause, as to the symptom 
which is likely to usher in the attack. If the cause is a moder- 
ate one, as excessive sexual indulgence, pain will generally begin 
some time before the general symptoms. If the cause is cold sud- 
denly and extensively applied to a menstruating patient, chills and 



ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. 127 

rigors may precede the pain. However that may be, when the 
case is fairly developed there is fever, aching in the back, pain in 
the head and extremities, flushed face, and furred tongue. In 
addition to these general manifestations there is local pain, indi- 
cating the organ affected. This pain may be confined almost 
entirely to the sacrum and lumbar region if the inflammation is 
moderate, but generally there is pain in the pelvis behind the 
pubis, or in one or both iliac regions. Sometimes the pain radi- 
ates in several directions up the abdomen, down the thighs, and 
around the body. The pain is usually of a dull aching, but some- 
times of a sharp character. In addition to these symptoms indi- 
cating inflammation in some of the pelvic organs, the nervous sys- 
tem is often affected with hysterical symptoms, convulsions, coma, 
laughing, crying, or unreasonableness of some kind. I should 
have mentioned among the local symptoms, dysuria, and difficult 
and painful defecation. Should the peritoneal covering become 
involved there is swelling, and greater or less tenderness of the 
abdomen. Nausea and even vomiting are not unfrequent symp- 
toms. 

After a week or more of this kind of suffering the symptoms 
gradually subside, and the patient slowly recovers her usual health; 
or sometimes the subsidence of the pains is not complete, and she 
continues to suffer with a chronic form of inflammation. The 
termination is almost always in resolution or the chronic form of 
the disease. Possibly, in some exceedingly rare instances, the force 
of inflammation is spent in some circumscribed locality, and it pro- 
ceeds to suppuration. I have lately seen an instance of this kind 
where the suppuration was in the anterior lip of the cervix. 

Prognosis. — The termination is so frequently in resolution or a 
moderate form of chronic inflammation, that we may almost always 
expect complete or partial recovery. Death probably never re- 
sults in uncomplicated cases of acute metritis, but unfortunately 
we occasionally meet with grave and even fatal peritonitis, appa- 
rently resulting from extension of the disease from the uterus. It 
has been my misfortune to have lately met, in consultation, with 
two instances of this sort. Although the prognosis is favorable as 
a general rule so far as the recovery of the patient from the attack 
is concerned, it is not so favorable for. the complete re-establish- 



128 ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. 

ment of health, as the patient is likely to be affected with chronic 
inflammation in the body or cervix. Not un frequently we trace 
chronic inflammation back to a moderate attack of the acute. 

Diagnosis. — Inflammation of the cellular tissue beside the ute- 
rus, metatithmenia, rectitis, or cystitis, cause symptoms which 
may be mistaken for metritis. When doubt exists it may be easily 
and certainly solved by a digital examination. If the bladder is 
the seat of disease, the tenderness complained of by pressing it 
between fingers in the vagina and others above the pubis will be 
sufficient proof; pressure may be made upon the rectum by in- 
cluding it between the introduced fingers and the sacrum. The 
inflammation at the side of the uterus, or cellulitis, causes tender- 
ness and hardness close to the iliac bones on the side, and the 
hardness seems to be continuous with the bones. The greatest 
tenderness is, therefore, close to the side of the pelvis. In all 
these cases the uterus may be touched, provided it is not moved so 
as to press upon the inflamed part or organ without causing pain. 
If it is the seat of inflammation the tenderness will be confined to 
that organ, while all the rest are free from it, and may be handled 
freely. We should not forget that all these organs may be impli- 
cated in one great mass of acute inflammation, and all the pelvic 
contents be intolerably tender to the touch. In an examination 
to diagnosticate inflammation of the uterus, I need hardly say that 
a resort to instruments is unnecessary. 

Treatment. — The intensity of the inflammation will govern us 
in the activity of treatment. If it is not attended with great pain 
or febrile reaction, although our remedies must be the same, there 
is no need of using them with the same energy. We should, how- 
ever, bear in mind the great likelihood of leaving the chronic form 
behind, and be diligent in our medicinal and hygienic appliances, 
until every vestige is gone, when practicable. If the attack is 
moderate, it may sometimes be interrupted in the beginning, by 
measures to induce a copious perspiration, more particularly if 
caused by an exposure to cold. Even a smart attack may some- 
times be relieved by a large dose of opium and a steam bath, used 
within a few hours after the commencement of the symptoms. 
After the symptoms have become fairly established and have 
lasted for twenty-four hours, we must not expect to find immedi- 
ate relief, and should begin the systematic use of antiphlogistic 



ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. 129 

treatment. In the subacute form, a brisk cathartic, foot-bath, and 
fomentations over the uterus, should be followed by tart, antimony, 
muriate of ammonia, and calomel. 1^. Ammon. hydrochloras, 5ij ; 
ant. et pot. tart. gr. j ; ext. glycyrrhiza, Sss ; aqua bull., oviij. 
Mix and dissolve. This is a good old formula, and may be taken 
in tablespoonful doses every four or six hours. Perfect quietude 
should be enjoined also, and rest at night may be insured by giving 
one grain of calomel, with twice the amount of opium, in a pill at 
bedtime. Continued for five or six days this will generally induce 
slight mercurial effect, when the pain and other symptoms will 
pretty surely subside. If it does not do so, a blister over or a little 
above the pubis will aid in banishing them. If the attack is se- 
vere, we ought to add to the above remedies the more immediately 
depressing. The patient may be bled from the arm until a decided 
impression upon the pulse is produced, or we may apply from ten 
to twenty leeches to the vulva and groins, as the depletant measure. 
In the country, where leeches cannot be had, scarification and cup- 
ping can be profitably substituted for them. Should arterial ex- 
citement be high after the depletory measure, the tinct. of verat. 
viride, in doses from four to six drops every four hours, with the 
ammon. mixture, will be an efficient adjunct to our remedial meas- 
ures. The calomel should be withheld as soon as its specific effects 
are produced. 

I should not discharge the obligation I feel to the student, in the 
treatment of this disease, were I not again to caution him against 
an imperfect cure of it. Very often it becomes chronic, and ren- 
ders the patient miserable for years. We should try to avoid this 
consequence. Too early a resumption of duties and active exer- 
cise should be especially prevented. When practicable, a continu- 
ation of treatment and avoidance of the causes which produced 
the inflammation, are of equal importance. As a means of per- 
fecting the cure which the more active treatment has brought 
about, the sedative effect of water affords us valuable aid. The 
sitz bath and vaginal injections are the modes of using it. The 
sitz bath ought to be used as much as the time and patience of the 
patient can be made to allow. An hour is short enough time, and 
two hours is better, twice or thrice in twenty-four hours. The in- 
jections should be copious, and may be used in the bath and of the 
same water. From two to four gallons of water ought to be passed 

9 



130 ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. 

through the vagina in this way each time the bath is used, by 
means of the perpetual rubber syringe. 

Acute Inflammation of Mucous Membrane of the Uterus. — I do 
not know that I have ever met with an uncomplicated case of acute 
inflammation of the mucous membrane of the uterus. Cases that 
I have seen have been connected with inflammation of the vagina, 
and have arisen as the effect of some poison directly applied to the 
membrane. Most of them were gonorrhoeal, but in some I have 
been puzzled to determine whether the poison of this affection was 
the cause or not. Probably this poison gets into families, where 
and in ways it ought not, and thus deceives us. However this 
may be, I think one of the worst features of gonorrhoeal inflamma- 
tion is the frequency with which it invades the mucous membrane 
of the uterus, and the difficulty of completely eradicating it. It 
is very apt to lurk in the uterus after the acute symptoms are re- 
moved and the inflammation gone entirely from the vagina, and 
thus require treatment as chronic endometritis. 

If I am not deceived by my observation, acute endometritis, of 
a non-specific character, is a very rare affection, and as I have not 
seen it and doubt its existence, I do not feel justified in compiling 
a description of it. 



CHAPTER X. 

CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

It would not be necessary to go into even a short detail of the 
sympathetic accompaniments of disease of the uterus, were I not 
convinced that they are often considered independent affections, 
and their origin not suspected by very many, if not the great 
majority of practitioners. It is my wish to impress the conviction 
that these diseases are overlooked, misunderstood, and neglected; 
and that an immense amount of suffering that is now borne as a 
necessity by women, might be relieved, if we would investigate 
and study their ailments with as much patience as, and with no 
more reserve than, we approach and investigate lung diseases or 
throat affections. 

Dr. Scanzoni* says: "The sympathetic phenomena which very 
distant organs so often present during the course of uterine dis- 
eases are of the highest scientific importance." They are the 
more important, because our attention is more frequently called 
to them than to their original exciting cause. The secondary or 
sympathetic diseases distress patients most, and the fact of their 
mentioning no other troubles may, without inquiry, mislead us 
into the opinion that they are independent affections. 

Sympathy of the Stomach. — The stomach is apt to be disturbed 
as early and as frequently as any other organ by chronic uterine 
disease. This is no more than we would expect, considering how 
often and intensely it is influenced by pregnancy, and its great 
readiness of complication in most affections of other parts of the 
system. Simple anorexia is, perhaps, the most common of the 
sympathies of the stomach, as is also its contrary, voracity ; but 
some unbecoming and even disgusting depravity of appetite is also 
not uncommon. Inappetency sometimes proceeds to the extent of 
loathing of food, and to longing for inappropriate articles of diet. 

* Diseases of Females. 



132 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

Nausea, with loathing of food and disgust at the smell of it, is 
another feature of stomachic trouble ; also, frequent vomiting when 
the stomach is full ; an absence of discomfort when it is empty, and 
the vomiting is sometimes worse when there are no ingesta, and 
nothing is expelled but some of its secretions, which are usually 
acid, but sometimes bilious. Gastralgia occurs when the stomach 
is empty; or during digestion, or immediately after swallowing 
food. The capacity of the stomach to digest food of any kind is 
often impaired, but more frequently some particular sort of food 
disagrees with the stomach and embarrasses digestion ; in short, 
almost every form of disordered stomach may be looked for as the 
result of the sympathetic influence of diseases of the uterus upon 
that organ. The grade of functional disturbance may vary from 
the slightest inconvenience to that complete arrest of digestion 
which rapidly induces inanition and death. Extreme cases of in- 
digestion, however, are not of frequent occurrence, and the dis- 
turbances are rather those of great annoyance than such as result 
in very serious impairment of nutrition ; and many patients who 
constantly complain of suffering very seriously from sensitiveness 
connected with digestion, attain to a state of apparent robust em- 
bonpoint. 

Sympathetic Disease of the Bowels. — The bowels probably sym- 
pathize in diseases of the uterus next in frequency to the stomach, 
and their functional derangements are multitudinous. Constipa- 
tion is very common. The bowels, in many instances, have appar- 
ently no natural tendency to move. I have one patient, who 
assures me that she often has been fourteen days without any fecal 
discharge whatever, and that she dare not try how long she could 
go without it, but that she always used some means to promote 
the alvine evacuations. In other cases, constipation terminates 
with diarrhoea ; and an alternation of diarrhoea and costiveness, 
which lasts from two to six days, is a constant and habitual state 
with the patient. In cases of constipation resulting from this 
cause, the constipation seems to depend upon a want of muscular 
tone in the intestines ; peristaltic action is deficient, and the ap- 
pearance of the evacuations is in all respects natural, and their 
consistence proper. In other cases the secretions are deficient, 
and the stools are dry, hard, and deficient in quantity. But con- 
stant diarrhoea and irritable bowels are also frequent accompani- 



SYMPATHETIC AFFECTIONS. 133 

ments of uterine disease. The passages may be profuse, watery, 
and exhausting, or profuse and fecal. A peculiar kind of dis- 
charge in cases of diarrhoea in uterine disease presents a muco- 
fibrinous cast of the intestines. These casts are sometimes quite 
tenacious, and of variable length, from two to ten inches, and are 
often complete casts of the intestinal tube ; at other times there 
are shreds of this false membrane of irregular shape and size. 
The discharge of these substances is usually attended with some 
dysenteric symptoms. The diarrhoea sometimes seems to be ex- 
cited or aggravated by certain articles of food ; at other times one 
kind of ingesta seems to agree as well as another ; and again the 
bowels may be quite regular, except at or near the period of men- 
struation. The irregularity is often entirely confined to that time. 
With or without diarrhoea there may be tumultuous gaseous com- 
motion in the bowels; they may be more or less distended, or with- 
out distension there may be annoying borborygmus and motion 
from the gas passing from one part of the bowels to another, in- 
ducing the opinion that pregnancy exists. The gaseous distension 
of the abdomen is sometimes so extensive and permanent as to in- 
duce the over-willing patient to believe that it is caused by ges- 
tation, and being connected with hysterical craftiness, she may 
impose the same belief on a careless practitioner. 

Sympathetic Affection of the Liver. — Closely connected with, 
and of course very much influencing the condition of the alimen- 
tary canal, is the condition of the liver. Sometimes the bile is 
poured out in such copious quantities as to induce full and free 
discharges of it from the stomach by vomiting, and to stimulate 
the intestines to copious bilious diarrhoea when they are not irri- 
table, but subject to the ordinary stimulation of ingesta. This 
overflow of bile comes in paroxysms, and produces a sort of cholera 
morbus. When it occurs only once a month, it is apt to be near 
the time of menstruation, but it may return several times between 
the monthly periods. But there is often a persistent absence of 
secretion for a time, or this condition may alternate with the 
other ; or the bile, instead of finding its way into the alimentary 
canal, may pass into the circulation and give the skin a jaundiced 
hue. When the functions of the liver are seriously disturbed, 
there is apt to be at one time a deficiency of bile, and at another 
a great redundancy. I have not seen this organ congested to any 



134 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

great extent, as observed by Dr. Bennett. But I have seen an 
enlargement of the spleen in such instances, though I have not 
supposed it to be the result of the influence of uterine disease. 
When these copious effusions of bile take place somewhat suddenly, 
all the pain and spasmodic action observed in bilious colic are likely 
to present themselves. 

Sympathetic Affection of the Nervous System. — Much more dis- 
tressing, if not more serious suffering, is experienced in the ner- 
vous system than in the digestive apparatus. Aches, pains, and 
complaints of evident nervous ailments, are the peculiar province 
of uterine disease. There is hardly a disagreeable or even ex- 
cruciating sensation that these patients do not experience ; and 
too often this real suffering is mistaken by the friends for imagi- 
nary, and the woman's complaints are treated with unreasonable 
impatience and rudeness by persons from whom she ought to re- 
ceive kindness and sympathy, because her appearance does not 
correspond with her morbid sensations, as we are apt to observe 
them in other examples of disease. It is remarkable, too, and a 
fact that often impeaches them with insincerity in their complaints, 
when the uninitiated are the judges, that these patients will pass 
from a state of excruciating suffering and loud complaints, under 
a little excitement, to one of actual enjoyment and hilarity, or 
conversely. The transition from the excitement of private com- 
pany, or a public party, gives way in a few minutes to a doleful 
condition of suffering and unappeasable complaints. The incon- 
sistency of the complaints and enjoyments, the incapacities and 
the performances of these patients, are almost characteristic — at 
least in their sudden alternation — and are inexplicable in any 
other way than by supposing that the pains in the different organs 
to which they are referred, are more dependent upon the general 
nervous susceptibility than upon the organic disease of even triv- 
ial character. They are strictly neuralgic in their nature, and 
confined to the nerve-matter or tissue of the parts. A great 
number of the disagreeable sensations and pains appear more fre- 
quently in particular parts, and hence may be distinctly referred 
to in this description. 

Cephalalgia. — Cephalalgia, in some form, either partial or gen- 
eral, is a very common attendant upon the nervous susceptibility of 
uterine patients. Often general, the whole head seeming to pul- 



SYMPATHETIC AFFECTIONS. 135 

sate and thrill with terrible pain, rendering the patient almost 
frantic with the intolerable aching. In a few hours general cephal- 
algia subsides, leaving the nervous energies prostrate for a short- 
time, but otherwise the patient is free from all pain. This sub- 
sidence would not be complete if the cephalalgia were anything 
but nervous pain in the head. These general cephalalgias are 
often, but not necessarily, attended by nausea and vomiting, or 
other stomachic, hepatic, or intestinal disorder ; and may be re- 
lieved, when that is the case, by emesis or an alterative cathartic. 
This is what is commonly called sick headache. The most frequent 
forms of pain in the head, however, are partial, and confined to 
some particular part ; as hemicrania, confined to the whole of one 
side, or a lancinating pain in the temple, brow, or eye. All these 
are very common pains in uterine disease ; but persistent or fre- 
quently recurring pain in the occipital region, or on the summit of 
the head, is nearly pathognomonic of uterine disease. It is almost 
invariably the case that a woman has chronic uterine disease if she 
complain of persistent pain in either of these regions. The occip- 
ital pain I have observed in this connection much oftener than the 
pain on the top of the head. It is ordinarily a dull aching, that 
completely unnerves the patient, and renders her unfit for her 
duties for some days ; it is usually very persistent, in some pa- 
tients being almost constantly present, but in other cases only 
occurring once a month, ordinarily at the menstrual period. The 
pain on the top of the head is described generally as a burning 
pain ; patients complain that they have all the time a hot place on 
the top of their heads. This pain is probably more constant in 
patients that have it, than is any other of the pains about the 
head. I think I have observed that when patients suffer greatly 
from pain in the head they complain less of suffering which is more 
directly referable to the uterus, than when any other symptom 
seems to exceed. Indeed, I have met with patients who were mar- 
tyrs to these excruciating headaches, that did not complain of any- 
thing which pointed directly to the uterus as the origin of their 
suffering, and yet upon examination that organ was found ulcer- 
ated and inflamed ; and when these conditions were cured by ap- 
propriate treatment, the headache ceased to annoy them. A re- 
markable instance of this kind occurred to me some years ago. 
The patient came to town to consult me about what she called 



136 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

neuralgia. The pain was located in the occiput ; it lasted one week 
in every four (her menstrual week), and when very severe she had 
hysterical convulsions. Convulsions occurred at almost every re- 
currence of the headache. She had no backache at any time ; her 
menses were natural in every respect, as far as I could gather from 
her history, on which I placed the more reliance, from the general 
intelligence of the patient. She could walk long distances without 
inconvenience, had no pains in the hips, groins, or legs ; in short, 
she made no complaint from which I could infer the origin of the 
nervous suffering to be in the uterus, except that the headache was 
sure to come on at the time of menstruation. Her uterus was 
ulcerated and inflamed ; and after appropriate treatment, was 
cured, when the suffering vanished, and she has since enjoyed com- 
plete immunity from them. This woman was about thirty years 
old, and in the midst of her child-bearing period, and it might 
hence be supposed that the uterus exercises more sympathy than 
at any other time of life; but, as the following case will show, this 
is not the fact : Mrs. , 49 years of age, had ceased to men- 
struate three years before I saw her, but was subject to the most 
excruciating headache every six or seven days, each attack of 
which would so prostrate her that she would scarcely recover from 
one before the next would appear. She had some backache and 
inconvenience in walking, but these symptoms scarcely attracted 
her attention amid the terrible sufferings caused by her headaches. 
Six months' treatment addressed to the uterus alone sufficed to re- 
move all this great trouble, and render the woman comfortable 
and capable of her duties in life. The overwhelming influence of 
this terrible cephalalgia on the nervous system seems to occupy 
so completely the capacities of it, that less pain is unheeded by it, 
and no cognizance is taken of the sufferings of the less sensitive 
but inflamed and mischief-making uterus. 

Affections of the Spinal Cord. — The spinal cord seems to par- 
take very much of this sensitiveness of the nervous system, prob- 
ably more so than the brain. Pain in some portion of the cord 
or cauda equina is almost universally present in uterine disease. 
The most common parts in which the pain is situated are the sacral 
and lumbar. Pain is so general in those regions, that it has come 
to be regarded as necessary in the estimation of very many persons 
to establish the probable existence of this affection. The pain is 



SYMPATHETIC AFFECTIONS. 137 

fixed and almost constant ; but aggravated by anything that excites 
the uterine vascular system ; as standing or walking for a long time, 
lifting or jumping, or sudden emotions. Fright, anxiety, or anger, 
as the patient says, "flies to the back," and aggravates this pain. 
It is especially apt to be worse during the menstrual congestion. 
Sometimes walking increases the pain so much as to incapacitate 
the subject of it from this kind of exercise. An expression often 
made use of to signifv sensitiveness of the back, is " weak back." 
Women will say, I have not exactly pain in my back, but it is so 
weak that I cannot move on account of it, or can hardly stand, 
or cannot arise from a stooping posture. The pain may be fixed in 
any part of the spine. I have a patient, whose backache is at the 
junction of the dorsal and lumbar region. In connection with 
these pains there is often tenderness in the same region, so that 
pressure causes great complaint. The pain is not only increased 
in the part pressed upon, but it sometimes darts along the nerves 
around the body. 

Sympathetic Pains in the Pelvic Region. — A number of painful 
localities is generally found about the pelvis ; in the inguinal or 
internal iliac region exceedingly common. Immediately above 
one of the groins a constant and fixed aching may be found, 
which is aggravated by all the circumstances that increase the 
pain in the back. Most generally there is some tenderness or 
soreness in the part in which there is pain, which is increased by 
pressure. This pain sometimes extends to the hip and side of the 
pelvis. It is much more frequent in the left side, but is often 
confined exclusively to the right, and less frequently it is in both 
right and left side alike. In more rare instances, the pain is cen- 
trally situated behind the symphysis pubis. 

Extension of Inflammation to Bladder and Rectum. — The pa- 
tient will often say she has pain in the bladder, or pain in the 
rectum, and believes that these organs are affected. These two 
last pains when complained of, are generally very appropriately 
stated to be in the bladder and rectum, and are indicative, for the 
most part, of an extension of inflammation to these two organs. 
When this is the case, pain accompanies or rather is increased by 
micturition, or immediately after it the pain may occur. The 
same remarks are applicable to the alvine discharge ; at that time 
the pain is increased, or then only occurs. These pains- are not, 



138 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

strictly speaking, sympathetic, but occur as consequences to the 
extension of the inflammation. The pains indicate correctly the 
locality of the inflammation. The pain in the iliac region some- 
times extends up the side as far as the mammary region ; or there 
may be pain in this latter region not connected with the former. 
The pain may likewise be situated between these regions and be 
independent of any pain in them. 

Affections of the Sciatic and Anterior Crural Nerves. — Pain in 
the course of the sciatic, obturator, or anterior crural nerve is very 
common in uterine affections of an inflammatory nature. These 
pains are often so severe and aggravated by any exertion as to 
incapacitate the patient from walking. Particular motions cause 
pain, according to the nerve affected. When the sciatic is the seat 
of pain, sitting down, especially on a hard chair, increases it, so 
that the patient resorts to cushions for defence against pressure. 
Pain in the course of one or more of these nerves is often the 
most distressing circumstance connected with the case, and it is 
often treated as neuralgia seated in these nerves, while the cause 
is not even suspected. The pain may occupy the whole length of 
the nerve, or it may be confined to its upper or lower parts, or to 
an intermediate portion of variable length. The part of the limb 
traversed by the nerve may be tender or not ; most frequently 
there is no tenderness. The pain may be fixed, or darting and 
transitory. It may be constant or paroxysmal ; the patient may 
enjoy immunity for hours and days, or even weeks, or she may be 
a constant sufferer from them. They are apt, as other pains are, 
to be greater during menstrual congestion than at any other time. 
The pains emanating from the pelvis are not sympathetic, nor are 
they probably reflex ; but they are caused very likely by pressure 
of the uterus on the nerves, or they may be produced by an ex- 
tension of the inflammation to the nerve sheaths. 

Hypercesthesia. — Akin to pains in various parts is hyperes- 
thesia without inflammation ; great sensitiveness of particular 
parts. Tenderness of the scalp is often complained of. The 
whole surface of the head is so tender as to require great care in 
dressing it, and no pressure can be tolerated without an effort. 
Of a similar nature is tenderness along the spine. The different 
spinous processes in some sections of the column cannot be touched 
without giving the patient great suffering. Pressure upon these 



MORAL AND INTELLECTUAL PERVERSENESS. 139 

tender vertebrae sometimes causes pain to shoot along the spinal 
nerves, passing out of the intervertebral foramina in the neighbor- 
hood. There is occasionally also general tenderness of the abdo- 
men. 

Anaesthesia. — Much less frequently there is anaesthesia of some 
particular parts. The patient complains of a want of the ordi- 
nary sensitiveness of the parts ; or there is a feeling of numbness 
which lasts for some days, and which recurs so often as to obtain 
the distinction of a symptom of the case. The muscular system, 
through the nervous, is in many cases very seriously affected. 
Cramps and spasmodic action are very frequent in particular 
cases, and they are confined almost constantly to certain limbs. 
They occur more frequently in the lower than in the upper ex- 
tremities. 

Spasms. — A worse state of things, however, exists when there 
are general spasms of the limbs and abdominal walls, and hyster- 
ical convulsions. They are apparently induced by fatigue, or 
occur at the time of menstruation. The patient, after complain- 
ing of severe pain in the stomach, falls into a state of general con- 
vulsions, which lasts from. thirty seconds to some hours, and sub- 
sequently sinks into a state of quietude, but not of insensibility. 
These attacks are usually repeated'several times and then subside, 
leaving the patient in the possession of her usual physical condi- 
tion, which is one of nervous miser}^. 

Accompanying Manifestations of Moral and Intellectual Per- 
verseness. — During the spasmodic action which, in the majority of 
cases, have to a critical observer the appearance of being partly 
voluntary, there is apt to be a singular perverseness of moral and 
intellectual manifestations, which was on a certain occasion very 
graphically expressed by a clerical friend in speaking of a patient, 
that she "seemed to be actuated by an evil spirit." In the midst 
of great suffering they not unfrequently try to bite and otherwise 
wound those who endeavor to restrain their violent agitation ; they 
attempt to throw the covering from them, with the apparent object 
of exposing their person, or say some very perverse things. At 
other times they attempt to imitate the symptoms of some grave 
organic affection. One patient, by heaving up the lower part of 
the chest spasmodically at rapidly succeeding intervals, induced 
her friends to think that she was the subject of violent palpita- 



140 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

tions of the heart, and therefore that she must be the subject of 
cardiac disease; she also imitated throbbing of the temples bj 
spasmodic contractions of the temporal muscle. When this throb- 
bing of the temples was very violent, I requested her to hold her 
mouth open so as to relax those fibres, but she looked up and said 
some very perverse things, and became contemptuously calm. A 
request to hold her breath when the palpitations were violent, in- 
duced her to act in the same way, and caused an instantaneous 
cessation of them. The great peculiarity in these spasms has al- 
ways seemed to me to be a guarded cunning, a deceitful and per- 
verted consciousness. To a close observer this is always easily 
detected. By using the foregoing epithets descriptive of the 
peculiarity of this kind of hysterical phenomena, I do not wish to 
be understood as saying that deceit, cunning, &c, are indications 
of freedom from disease on the part of patients who are thus af- 
fected. I think this is not usually the case, but that these indi- 
cations are the result of the morbid state of the mind and body. 
The spasmodic action of the muscles is not contemporaneous in 
the corresponding extremities as in epileptiform hysteria or epi- 
lepsy ; but is so irregular as to move the body in many different 
directions, instead of giving to it frequently repeated similar mo- 
tions. I do not know that I have seen the epileptiform hysterical 
convulsions arise from uterine disease. 

Syncopal Convulsions. — But there is a singular variety of semi- 
convulsions or syncopal convulsions, which I have noticed in a 
few cases, that I do not remember to have observed in any other 
connection. They occur very frequently after they have once 
seized the patient, as often as three or even six or eight times 
during the twenty-four hours. They take place in the daytime 
or at night, during the sleeping or waking condition, and do not 
seem to result from any particular excitement at the time. If 
the patient is sitting and talking, or is engaged in work, she sud- 
denly ceases, and slowly sinks down to the floor ; she turns her 
head to one side, almost ceases to breathe, becomes pale and trem- 
bles, sometimes very gently, sometimes violently. This state 
lasts only for a few seconds ; she arouses, looks about confusedly, 
and although she knows she has had a fit, as her friends call it, 
she does not remember distinctly anything which passed during 
the time. As these attacks become chronic, they may be attended 



AFFECTIONS OF THE CIRCULATORY SYSTEM. 141 

with very slight convulsive movements, frothing at the mouth, and 
sequential somnolence ; but, ordinarily, this is not the case. If 
the patient is attacked in the night while asleep, unless some per- 
son observes the attack, it will not be known to have occurred, the 
patient being unconscious of it. There is generally, however, 
movement enough to awaken anybody who may be in the same 
bed with the patient. In all cases of this kind, I have noticed 
great impairment of memory, particularly of recent circumstances, 
followed after a while with impairment of other mental faculties, 
and finally dementia. There is not usually any severe pain in the 
head or spinal centres ; there is, in fact, no prominent painful cir- 
cumstance apparently connected with the case. Patients having 
such paroxysms are generally worse at or near the time of men- 
struating; but sometimes they are quite exempt from them at this 
time, and have them not long after menstrual congestion is over. 

Muscular Weakness. — Extreme muscular weakness — I do not 
mean that which results from general debility, but of some par- 
ticular set of muscles — is often present as an accompaniment of 
uterine disease. This is most frequent in the back and lower ex- 
tremities, not often in the upper extremities. It is probably im- 
perfect innervation of the part, or it may be some affection of the 
muscles themselves. I have been inclined to look upon it as par- 
tial paralysis, resulting from reflex irritation. More or less numb- 
ness of the parts exists in connection with the weakness of the 
muscles. 

Circulatory System. — The circulation and its organs are very 
often deranged to a distressing degree. Palpitation of the heart 
is often troublesome, and patients are apt to think themselves the 
subject of disease of the heart. We are often consulted solely 
with reference to this symptom, it having absorbed the attention 
and awakened the apprehension of the sufferer to such a degree 
that her other inconveniences were forgotten or overlooked. 
These palpitations are sometimes attended with pain in the region 
of the heart, which occasionally shoots up to the left shoulder and 
down the left arm to a greater or less distance, the distress being 
so great as to amount almost to angina. The palpitation is worse 
during nervous excitement. It occurs generally in paroxysms. 
We meet with instances in which it oftener occurs after lying 
down at night than at any other time. Sometimes it seems to be 



142 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

increased during digestion. The sensation of palpitation does 
not seem to be at all commensurate with the increased excitement 
of that organ, and vice versa. I have observed instances in which 
the patient complained of violent palpitation, while the pulse and 
heart, as far as I could judge, were not at all disturbed. In such 
cases we might say that the sensitiveness of the heart was increased 
until its ordinary motions were perceived by the patient. Indeed, 
the pains and increased irritability of the organs supplied with the 
great sympathetic nerves, seem to result from increased suscepti- 
bility or sensitiveness instead of organic changes. There is also 
sometimes a sensation of throbbing, as though the blood was pass- 
ing through the arteries in increased quantities, and with increased 
force in some parts of the system ; this occurs mostly about the 
head, sometimes in the hands and feet, and occasionally inside 
the head, apparently in the brain ; also about the genital organs. 
Great irregularity of distribution of the blood is often observable, 
the hands and feet being uncomfortably cold, and continuing in 
that state for twenty-four hours at a time. In connection with 
cold extremities, the head is apt to be hot, or warmer than nat- 
ural ; this heat of the head may also be present when the feet 
and hands are of the common temperature. This heat about the 
head and face is sometimes almost constantly present in certain 
patients, and is the source of great annoyance to them. It is apt 
to be caused by anything that excites the person. The heat is 
greatest and frequently exclusively located on the top of the 
head. I do not think that this sensation of heat arises from any 
other cause as frequently as from uterine disease, and I am sure 
it is one of the most common symptoms in such disease. There 
is great heat complained of in the back of the head also, in many 
instances, and sometimes it extends along the spine, affecting the 
whole or only sections of it. Burning in the sacrum and loins is 
very common. Flashes of heat and flashes of color in the face 
and head, and even in other parts of the body, are very common 
and annoying occurrences. ■ The power or nervous energy of the 
heart may be impaired to such an extent as to render the patient 
liable to faintness on the application of very slight causes, — anger, 
fear, surprise, or even the more tender emotions, overcoming the 
patient very readily. 

Mesjnration. — The respiratory apparatus is not so frequently or 



AFFECTIONS OF THE RESPIRATORY APPARATUS. 143 

so severely affected as some of the rest of the organization ; and 
yet we often meet with some very curious and considerable devia- 
tions from the natural condition of its functions. The constriction 
about the throat, or the feeling as if a ball rose up to the throat 
and obstructed respiration, and the feeling as if smoke or dust was 
in the air which the patients breathe, are complaints we hear 
almost every day. All these sensations, or any one of them, may 
be aggravated to an agonizing degree, inducing the fear that the 
paroxysm may be fatal, and causing the patient to suffer for some 
moments, and sometimes for hours, the horrible sensations of im- 
pending suffocation. The breathing may be spasmodic from painful 
and unnatural contractions of the respiratory muscles. There may 
also be pleurodynic pains during each ordinary effort of respiration. 
Imperfect respiration, or partial inflation of one lung, or of parts 
of the lungs, occasionally occurs. The modification of the respi- 
ratory murmur arising from this imperfect inflation of one of the 
lungs I have observed on several occasions, and not without serious 
apprehension of the result ; but in all cases where this was the only 
modification of physical sounds, the patients have done well, and 
the inflation improved as the returning nervous energy of the rest 
of the system was established. The respiration is not often apt 
to be hurried as a constant circumstance, but occurs as the effect 
of excitement from mental or moral emotions. In some cases, amid 
the tumult of nervous excitement during a paroxysm, I have seen 
the respiratory efforts increased to sixty in a minute ; and, gen- 
erally, these nervous patients constantly have increased frequency 
of respiration. • There are cases in which cough is a very constant 
symptom ; it is a peculiar, nervous cough, as a general thing, and 
is excited or made worse by anything that renders the patient more 
nervous. Sometimes it is difficult to distinguish it from the coughs 
which arise from insidious affections of the lungs. It is possible 
that the coughs arising from slight lung difficulties may be aggra- 
vated by the nervousness consequent upon uterine disease. I once 
saw a patient affected with a peculiar nervous cough as the effect 
of uterine disease, which sounded like the barking of a small dog, 
and the sound was made at every expiration during the waking 
condition of the patient, except when the mind was intensely occu- 
pied. She was an intelligent young married woman, about twenty 
years of age. While her whole attention was absorbed, she forgot 



144 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

to cough, but as soon as her attention was relaxed, she habitually 
produced the same sound. This had lasted when I saw her six 
months or more. When she was embarrassed bj a conversation 
which related to her case, the sounds became much louder and per- 
sistent, appearing in perfect synchronism with every respiratory 
effort. It must be added, that I did not have an opportunity to 
treat this patient, nor have I heard from her, so that I cannot give 
her subsequent history ; but the rest of the symptoms plainly in- 
dicated uterine suffering, and an examination established the fact 
that she had inflammation and ulceration of the neck of the uterus. 
She had never borne children, or miscarried. 

Sympathy of the Excretory Organs. — The excretory organs also 
sympathize with the uterus, particularly the kidneys. It has been 
a long time observed that female patients, in a state of nervous ex- 
citement, secrete a large quantity of urine, which is usually limpid, 
almost odorless and insipid. These qualities are most likely depend- 
ent upon the amount of water being so much greater proportionately 
than the salts : these last scarcely seem to be present at all. It is 
extremely dilute urine. Uterine patients are very prone to these 
large discharges of limpid urine. This kind of alteration in the 
functions of the kidneys is, doubtless, indirect, and does not occur 
except in connection with a greatly excited condition of the nervous 
system as the medium between the kidneys and the uterus. More 
considerable deviations, however, are apt to take place ; the salts 
are likely to be increased in quantity compared to the amount of 
water ; or one sort of the salts may be greatly over or under the 
proper proportions in relation to the others. The urine may be 
decidedly morbid in its composition. It is probable, too, that this 
deviation is secondary to derangements of the stomach and liver, 
but nevertheless, it is often present. The urine may be highly 
alkaline, or highly acid in reaction, showing the production, to an 
unusual degree, of salts having such chemical qualities. The pres- 
ence of these salts in excess, whether of the one kind or the other, 
is pretty sure to produce painful micturition and other disagreeable 
sensations, as burning and smarting in the urethra and bladder. 
There is no doubt, however, that these painful and disagreeable 
symptoms may arise as the more direct effect of inflammation of 
the uterus when the urine is correct in composition ; hence the ex- 
amination of the urine will be necessary to determine the cause of 



MORAL AND MENTAL DERANGEMENT. 145 

the symptoms. But the urine is often secreted in very diminished 
quantities in cases of uterine disease ; and that, too, without ap- 
parent general febrile excitement. Patients frequently complain 
of this symptom. Whether there is an increase in the excretory 
functions of the skin at such time, I am unable to say. The skin 
is probably not very much affected in its excretory capacity as a 
general thing, but some very curious deviations have been observed. 

Mammary Bodies. — More direct are the effects upon the mam- 
mary bodies. They are often highly excited by uterine disease ; 
this is no more than would have been expected from the close sym- 
pathetic relations between these organs. Congestion is the most 
common sympathetic condition. The mammae increase in size, be- 
come hot and painful as a general thing, but sometimes there is no 
change in their sensible or sensitive conditions. The appearances 
are natural, but the patient complains of a peculiar and painful 
condition, not unlike the sensations perceived during the suppura- 
tive stage of inflammation; but there «is neither tenderness, nor 
swelling, nor heat, nor other deviation, than the unnatural sensa- 
tion. Sometimes the breasts are really inflamed. The lymphatic 
glands in the axilla, and from the axilla to the border of the mammae, 
in some instances, become affected at the same time ; in other in- 
stances, however, they do not partake in the sympathies of the 
mammae. They also become tender in some cases when the mammae 
do not seem to be excited. 

Moral and Mental Derangement. — No more constant derange- 
ments, perhaps, occur, than are observed in the mental and moral 
qualities of the patient. The patient loses the complete control 
which she has been in the habit of exercising over her emotions, 
and finds herself becoming despondent, fretful, suspicious, and 
unsteady in her purpose; whimsical, having desires not before ex- 
perienced, indulging in thoughts and feelings toward her friends 
which in her former days she did not entertain. She will often call 
herself a changed woman. If the source of irritation is not dis- 
covered and removed, she loses her strength of will entirely ; and, 
instead of her moral feelings being guided by her will under the 
influence of a sound judgment, she exhibits indecision, and wavers 
in matters about which she heretofore had no difficulty in making 
decisions. She finds herself giving way to peevishness to a frightful 
degree ; nobody can please her. In place of her usual satisfaction 

10 



146 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

in the attentions of her friends, she finds fault with their efforts to 
make her comfortable. Sourness, moroseness, jealousy, careless- 
ness, timidity, and some peculiar perverseness, change her nature 
entirely. Sometimes one class of ideas will seize her whole facul- 
ties, and she will scarcely think or talk of anything else. She has 
no patience with anybody who will not listen to her, and believes 
everybody to be her enemy who cannot sympathize with her in her 
imaginary troubles. The different phases of mental and moral 
troubles under which the patient labors are almost innumerable. 
As will be seen, this state of things is closely bordering on insanity, 
and there is no doubt that insanity is often the result of uterine 
irritation in patients who are hereditarily predisposed to it. I think 
I have seen cases of insanity that were excited into activity by the 
great nervous irritation connected with uterine disease. But, in 
place of this steady deviation from her natural mental condition, the 
patient may generally be sane, and show an abnormal state of mind 
only when circumstances occur which are likely to excite her, when 
she loses all control and indulges in excessive anger. Sometimes, 
in a fit of despondency or melancholy, she contemplates or even 
attempts suicide. Or, if her sense of wrongs weighs heavily upon 
her, and no means of redress shows itself, she thinks seriously of 
fleeing from what she fancies is the cause of them. Still another 
sort of paroxysm exhibits the acts of a depraved and indecent na- 
ture ; so disgusting as to shock the witnesses of them, and in her rec- 
ollection of them to mortifv her exceedingly. The common hyster- 
ical paroxysm of crying without a sufficient cause, the indulgence 
in unbecoming and unseemly levity, rapid transitions of despon- 
dency and hope, need hardly be mentioned, from their familiarity 
to every observer. When, in reference to such unbecoming exhi- 
bitions, patients are kindly remonstrated with, they will, in general, 
acknowledge the impropriety of them, but will end with saying, " I 
cannot help it;" which is the unanswerable and doubtless truthful 
exposition of their mental condition. Neglect of duty in all the 
relations of life is one of the phases of their mental state. Some- 
times a wilful selfishness, caring for nothing but what they fancy 
will make them happy, or conduce in some way to their interests, 
absorbs their whole mind and governs all their actions. At times 
there is an intelligent appreciation of the impropriety of their 
actions. 



SYMPATHETIC AFFECTIONS. 147 

I have dwelt so long on these general symptoms, and have made 
so much of uterine sympathies, that I am forced to recall an expres- 
sion made use of in a notice of Professor Hodge's work on "Dis- 
eases of Women," that "if all this is true, it is almost a pity that 
a woman has a womb ;" but I conscientiously believe I have fallen 
very far short of mentioning all the sympathetic evils resulting 
from chronic diseases of the uterus, and I only design this as an 
outline view of a subject that will fill itself up in painfully warm 
colors in the observation of those who devote themselves to a close 
study of the diseases of women. While this is my conviction, I do 
not wish to be understood as saying that nearly all of the above 
symptoms will show themselves even in a majority of cases : some 
of them will be prominent in some cases, others in other cases ; and 
in rare instances we meet with nearly all of them in some sufferer, 
and in nearly all chronic cases we shall find enough to move us to 
commiseration for the ruined health of women thus affected. I 
know there are thousands of my peers in the profession, who do 
not see in the foregoing array of symptoms any indication of dis- 
ease of the uterus; and when uterine diseases are obviously co- 
existent, they are apt to be arranged in the order of sequency. 
This does not shake my faith in the facts I have observed for my- 
self, nor disturb my judgment formed from an observation of a 
very large number of cases carefully watched through all stages of 
progress to their termination. That all the above symptoms may 
occasionally be present in cases in which the uterus is healthy, I 
have often observed ; but that they are also frequently present as 
the proximate and remote effects of uterine disease, I am well sat- 
isfied. Another well-established fact, according to my judgment, 
is, that the direct symptoms referable to the uterus may be feebly 
pronounced, while some or even a large number of the sympathetic 
disturbances are very prominent; and judging from the freedom 
of pain and other inconveniences experienced in the uterine region, 
there are even cases in which the uterus does not seem to suffer at 
all. These cases are well calculated to mislead us, and to induce 
the opinion that the womb difficulty is of minor importance, and 
need not be the object of solicitude until we get rid of the more 
troublesome and prominent symptoms. We cannot be too careful 
in our consideration and management of this class of cases, and I 
insist, that while we adopt judicious remedial means for the re- 



148 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

moval of the more afflicting symptoms, that we be sure to address 
ourselves to the disease of the uterus, however slight it may appear 
to be. I have seen too much good result from the observance of 
this direction not to dwell with emphasis upon its importance. The 
cure of the uterine disease will be a valuable diagnostic measure 
in such cases. Not only may there be a great difference or want 
of correspondence in the severity of the local and general symp- 
toms, but in many cases in which the general symptoms have almost 
made a wreck of the health and happiness of the patient, the local 
inflammation and ulceration will be found upon examination to be 
trifling in amount and degree. The inflammation* may be very 
slight and the patient suffer very greatly from it, either generally 
or locally, or both : or the ulceration may be extensive and the 
inflammation very considerable, and yet the patient hardly be sen- 
sible of any inconvenience whatever from its presence. This state- 
ment will be confirmed by careful observers in this field of re- 
search. It, however, will prove a stumbling-block to those who 
entertain the opinion that uterine disease is of small importance in 
the consideration of woman's ailments. They seem to think that 
there is of necessity an exact and invariable correspondence be- 
tween the magnitude of cause and effect, and they point to these 
cases and say, — the symptoms were present, but very trifling, if 
any, uterine disease showed itself upon examination ; or they will 
say, there was great ulceration, but the patient did not suffer from 
its presence, at least not in proportion to the amount of local dis- 
ease. I need not particularize instances in which other diseases 
are comparatively latent, or cases in which the symptoms are un- 
duly severe compared to the amount of actual disease, as they will 
suggest themselves to every intelligent practitioner. But recurring 
to the sympathies of the uterus, we find that while some patients 
are not affected at all by pregnancy and others are favorably 
affected, their health being better then than at any other time, 
that some absolutely perish on account of the same functional de- 
rangements inaugurated by pregnancy ; and, as is shown on a 
former page, organic diseases are not unfrequently lighted up. 
We will probably always be at a loss to understand precisely this 
difference ; but there can be no doubt that it is more on account 
of constitutional differences than local ones. The concatenation 
of sympathetic influences may be caused by the greater suscepti- 



SYMPATHETIC AFFECTIONS. 149 

bility of the organs secondarily affected. In fact, the only mode 
of accounting for it is by supposing this increased susceptibility. 
I am convinced that this great but inexplicable diversity of sym- 
pathetic effects is as likely to result from uterine disease as from 
pregnancy. We must expect a very great range of difference in 
the extent of sympathetic derangement from uterine disease. It 
is interesting to observe the rise and development of the sequences 
to diseases of the uterus. How far can the uterus produce a direct 
effect in creating this large amount of sympathetic disorder? Are 
most of the symptoms produced by the direct sympathetic relation 
of the uterus to other organs, or does the diseased uterus first 
affect some other more influential organ detrimentally, and then 
this last the organism generally ? I am inclined to think, from a 
large observation, that the uterus has direct sympathy with only 
a few organs, and no one probably is so powerfully affected by it 
as the stomach. It is the first organ affected by it in pregnancy, 
being brought into a morbid condition in a very few w T eeks. The 
well-known, powerful, and almost universal sympathetic influence 
exerted by the stomach upon other viscera is sufficient, when it is 
diseased, to account for the great variety of subsequent symptoms. 
The stomach is the great centre from which radiate abdominal, 
thoracic, cerebral, and spinal disturbances almost ad infinitum. 
And there can be no reasonable doubt that it is an active agent in 
originating the disturbances of the great vital organs. The subject 
of the sympathetic influence of the uterus then becomes the more 
interesting and important, from the fact that very slight deviations 
from its ordinary condition arouses the most influential of all the 
organs to a state of disease, which depresses the functional energies 
and increases the susceptibilities of almost all the rest of the organ- 
ism. In addition to the chain of sympathetic susceptibilities pro- 
duced by this state of the stomach, too frequently the digestive 
powers of that organ are impaired or perverted, so as to supply the 
chyme in deficient quantities or in deteriorated quality, and in this 
way injuriously affect the composition of the blood, inducing anaemia 
or oligemia. Imperfect nutrition will follow, as a matter of course, 
in the one case, and perverted nutrition in the other, so that ema- 
ciation or obesity will be ordinarily present. Another organ prob- 
ably in direct sympathy with the uterus is the cerebellum, as it 
seems to me to be as frequently affected as the stomach. The 



150 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

mammae are, of course, in direct sympathetic relation with the 
uterus, and yet they are not uniformly affected in many cases when 
the uterus is very seriously diseased. I do not believe that we are 
able to say, at present, whether there are other organs that come 
directly under uterine influence. A proof of the powerful and very 
ready effect upon other organs of irritation of the uterus, may be 
found in the fact, that very often when the patient is in a condition 
of comfort, so far as her general suffering is concerned, an appli- 
cation of nitrate of silver to a morbid os uteri will give her ex- 
cruciating pain in the head, render her exceedingly despondent 
and irritable, and very much aggravate the symptoms with which 
she is affected. This I have so often observed to be the case, that 
I cannot but regard it as one of our diagnostic means. After such 
an application, the patient will generally complain of an aggrava- 
tion of the general symptoms, whatever they may have been, and 
say that all the pains are made worse by the application of the 
caustic. When an organ has been the subject of irritation or 
functional derangement for a long time, in consequence of sympa- 
thy with the uterus, it may become the subject of organic disease, 
and then continue as an independent affection of perhaps a danger- 
ous character ; or if organic has not succeeded to functional dis- 
ease, the power of habit which is so frequently thus engendered 
will perpetuate morbid action for an indefinite period after the 
cause of it has been removed. 



CHAPTER XL 

CHRONIC INFLAMMATION OE THE UTERUS AND CERVIX. 

Local Symptoms. — The symptoms which more directly indicate 
inflammation and ulceration of the cervix uteri, should be dwelt 
upon with some minuteness. Some of the symptoms have been al- 
ready mentioned, and the rest are reserved for a separate notice. 

Pain in the Sacral or Lumbar Region. — Pain in the sacral or 
lumbar region is one of the most constant, and when persistent, 
indicates, with a good deal of certainty, disease of some kind in the 
pelvis. The pain in these regions which is caused by the uterus 
is ordinarily central, being in the middle of the sacrum at its lower 
extremity. It is sometimes at its upper extremity, or it extends 
the whole length of this bogie. Not unfrequently a painful spot 
may be found on one side, over the sacro-iliac junction. Some 
patients describe the pain as if a bundle of nerves were pulled 
upon from the inside of the sacrum, and others describe it as an 
aching or burning pain. Accompanying the pain in the sacrum 
is often a sense of soreness upon pressure, an inability to sit with 
comfort, on account of the tenderness of the lower part of the 
sacrum. 

Pain in the Loins. — Pain in the loins is probably not so com- 
mon as that in the sacrum, but is quite as various in its nature. 
Very frequently there is great weakness in the loins, to so great 
an extent sometimes as to prevent the continuance of the erect 
posture for any length of time. 

Inability to Stand. — I have had a number of patients who were 
unable to stand upon their feet long enough to dress their hair, on 
account of the weak back. It is remarkable that patients often 
feel this weak back more when standing than walking ; and they 
are sometimes able to walk a distance, without any great incon- 
venience, but as soon as they stop, the weakness is apparent to a 
distressing degree. 

Inability to Walk. — Ordinarily, the weakness disables the pa- 
tient from walking. The pain in the back is almost always in- 



152 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

creased by walking or standing, and on this account the patients 
avoid being on their feet, although the back is strong enough. 
There are many patients who have severe inflammation of the 
cervix, who do not experience any of the inconveniences in the 
sacrum and loins already described ; but some of them are very 
generally present. 

Great pain in the back, closely resembling pain arising from 
diseased uterus, is also caused by haemorrhoids, prolapse, or in- 
flammation of the rectum. The pain caused by diseases of tire 
rectum, I think is much more frequent on the left side of the sac- 
rum, and in the left nates or hip, than centrally situated; in fact, 
I have come to regard pain confined to the left nates and hip, as 
indicating, with considerable probability, rectal disease, and I al- 
ways inquire into the functions of that organ, when that pain is 
present. It differs in position from the pain in the iliac region, 
so common as the result of uterine disease. It is situated near 
the sacrum, and more in the side of the pelvis than the latter. 

Pain in the Iliac Region. — Pain in /the iliac region is very com- 
mon. In frequency, it is next to pain in the back. The pain is 
commonly situated near the anterior superior spinous process 
of the ilium, and below the level of it. It is not referred to the 
iliac bone, or fossa, but to a place a little above the groin. We 
often meet with it on both sides, but much more frequently on one 
only ; on the left side much oftener than on the right. Dr. Dewees 
considered this pain in the left groin, or a little above it, as almost 
diagnostic of prolapse of the uterus. It is certainly very fre- 
quently indicative of inflammation of the uterine cervix. 

Soreness in the Iliac Region. — This pain is generally accom- 
panied with soreness upon pressure, and sometimes there is sore- 
ness upon pressure when there is no constant pain. Walking, 
standing, or riding generally increases it. A severe shock or 
strain, from lifting, will sometimes cause pain suddenly to appear 
in this region, when it had not before been observed. 

Pain in the Side, above the Ilium. — Instead of the pain situa- 
ted, as here described, there is often pain higher up in the side, or 
in the iliac fossa, or along the crest of the ilium, and even mid- 
way between the crest and ribs of the side. These pains are not 
in the ovaria, although they seem to point to the ovaria more di- 
rectly than to the uterus, and are by some regarded as a symptom 



LOCAL SYMPTOMS. 153 

arising from ovarian inflammation. Dr. Bennett admits that it 
may be a sympathetic painful condition of the ovary. It is not 
material whether this is true or not ; it is certain that it is very 
frequently present in uterine disease, and almost invariably cured 
by remedies addressed to the uterus, instead of to the ovaria. 

Weight, or B earing -doivn Pain, or Uterine Tenesmus. — An- 
other indication of uterine disease, of less frequent occurrence, is 
a sense of weight in the loins or pelvis. This sense of weight is ex- 
perienced in the loins and iliac regions more frequently than else- 
where ; but it is often felt at the pelvis, and oftener in the perineal 
and anal regions. Patients express themselves as feeling a heavy 
weight dragging upon the back and hips, and others feel as though 
the insides were dropping through the vagina. Occasionally we 
meet with such urgent uterine tenesmus, that the patient is obliged 
to keep the recumbent posture, in order to enjoy any comfort. 
In these cases, the patient in the erect position cannot resist a 
constant desire to "bear down," resembling the tenesmus of dys- 
entery. This sensation is sometimes more distressing than any 
other symptom, and obliges the patient to desist from walking. 

Leucorrhoea. — Leucorrhoea is one of the symptoms usually re- 
lied upon as an evidence of disease of the uterus. In the healthy 
condition of the uterus and vagina, there ought to be no discharge; 
the vaginal canal is merely moist, and no mucus should make its 
appearance externally. When the mucous membrane is tempo- 
rarily excited, there is more than ordinary secretion ; but it ceases 
as soon as the cause of excitement passes. 

Effects of Inflammatory Excitement. — We should a 'priori expect 
increased vaginal discharge to be accompanied with some form of 
disease, especially when it continues for more than a few days. 
Our knowledge of the discharge from mucous membranes lining 
the cavities elsewhere, will afford us enough data to confirm these 
views. We do not expect to see a constant flow, however moder- 
ate it may be, from the male urethra, when it is perfectly healthy ; 
and we take gleet as an evidence of chronic urethritis, and it is gen- 
erally the sequence of an acute attack of that disease. A constant 
discharge from the nose is an evidence also of more or less disease. 
It is just so with the vagina. The indications from leucorrhoea 
are derived from the color or consistence of the discharge, or 
both. The discharge from the vagina, resulting from mere ex- 



154 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

citement of the mucous crypts, is thin, glairy, and not very tena- 
cious. It is ordinarily acid in reaction. There is no color, and 
but little consistence to it. When a moderate excitement of the 
internal mucous membrane of the neck of the uterus produces a 
discharge of mucus, sufficient to appear at the orifice of the 
vagina, the discharge is white, not unlike milk, and when ex- 
amined closely, will be found to consist of minute coagula swim- 
ming in a little clear fluid. When the mucus flows from the 
mouth of the uterus, it is thick, and resembles very closely the 
albumen of an egg, and is alkaline in reaction. When it passes 
into the vaginal canal, it meets with the acidity of the vagina, 
and is coagulated, and the whole changed from a colorless trans- 
lucency to an opaque white. The reason that the coagula are 
small and so numerous, may probably be found in the fact that 
mucus arrives in the vagina in such small quantities ; each 
coagulum represents a minute drop of mucus, changed in qual- 
ity. As, however, the mucous membrane of the vagina fur- 
nishes only a small quantity of acidity, when this alkaline dis- 
charge from the cervix is copious it soon neutralizes the vaginal 
acid, and passing through this cavity unchanged, appears at the 
external parts possessing its characteristic qualities. We then 
hear the patient complain of a tenacious albuminous leUcorrhoea ; 
she will nearly always compare it to the white of an egg, but 
state that it is more tenacious. Unless the quantity is consider- 
able, the mucus from the internal cervical membrane does not ap- 
pear at the external orifice unchanged, but passes into this cur- 
dled condition. There is often a considerable quantity of this 
milk-like leucorrhoea in the whole length of the vagina, and hence 
it has been supposed by many that this is the vaginal mucus, in 
its natural condition, and they have called it vaginal leucorrhoea. 
I am satisfied that it is changed cervical mucus. 

Character of the Mucus in the Vagina. — The vaginal mucus 
does not undergo any kind of coagulation, but appears at the 
vaginal orifice as a clear, thin, almost watery fluid, which moistens 
but does not stain the linen. This colorless mucous secretion is 
indicative of increased vascular and glandular excitement, without 
detriment to the integrity of the membrane whence it is derived, 
and the excitement may be due merely to temporary congestion, 



LOCAL SYMPTOMS. 155 

in which case it will disappear, or it may be inflammatory, when 
it will become more persistent, and possibly permanent. 

Amount of Leucorrhoea not always Proportioned to Extent of 
Disease. — The abundance of this discharge is no criterion by 
w T hich to judge of the amount of inflammation, or its intensity, but 
it will scarcely remain colorless after the integrity of the mem- 
brane is invaded. When the albuminous fluid appears at the ori- 
fice of the vagina, there is persistent cervical disease, almost of a 
certainty. 

Yelloiv Leucorrhoea, ivhen there is Inflammatory Ulceration. — 
The thick, white-of-egg-like albumen will be mixed, when there 
is ulceration in the cervix, to a greater or less extent, with pus, 
so that it will be stained yellow. If the quantity of ulceration is 
considerable, and its surface is producing pus, the yellow will pre- 
ponderate in the color, and sometimes the whole of the production 
becomes yellow. The yellow color may be in streaks through it, 
or intimately mixed with it, so as to stain it uniformly ; or the 
pus may be mixed with the white creamy secretion found in the 
vagina. Pus may be mixed with any of the varieties of leucor- 
rhoea, and impart to it its tint, more or less completely. 

I am in the habit of considering the pus-colored leucorrhoea as 
indicative, with great certainty, of destructive or ulcerative in- 
flammation of the mucous membrane of the genital canal. This 
inflammation may be situated in the vagina, in the cervix of the 
uterus, or in the uterine cavity ; and I can hardly conceive of the 
production of pus by a mucous membrane with a whole epithe- 
lium. 

Ulceration sometimes exists without Leucorrhoea. — While I am 
almost confident of the existence of ulcerative inflammation some- 
where, when this purulent leucorrhoea shows itself, and persists 
for some time, I am not, on the other hand, at all confident that 
ulceration does not exist, if the yellow leucorrhoea is not present. 
Indeed, I do not regard leucorrhoea necessary to establish the 
existence of ulcerative inflammation. There are many cases in 
which it is quite evident that mischievous inflammation is plainly 
the cause of the invalid condition of the patient, and yet neither 
mucus nor pus ever shows itself at the vaginal orifice. This may 
probably be attributed to two circumstances : in the first place, all 
ulcerated surfaces do not discharge pus, or if pus is discharged, it 



156 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

may be in very small quantities ; in the second place, the absor- 
bents of the vagina may be so active as to take it up before it 
arrives at the external parts. Cases have been observed in which 
a large secretion is caused by a small amount of ulcerative dis- 
ease. Notwithstanding the fact that in uterine disease leucor- 
rhoea is a common and significant symptom, it will not do to base 
an absolute opinion on its absence, in any given case. 

How is the Pain Produced ? — How are the local painful symp- 
toms produced ? Is the pain in the groin or ilium caused by pro- 
lapsus and traction on the broad or round ligaments ? I think 
not. Pain and sensitiveness in the ilium are so frequently pres- 
ent, when I cannot detect any kind of displacement, and so gen- 
erally disappear when the inflammation is cured, that I am con- 
vinced displacement is not necessary for their production. They 
are of that character of pains which range themselves in the cate- 
gory of that vague, yet indispensable term, sympathetic ; or, of 
the not less fashionable, yet equally indefinite term, reflex. 

Bearing Doivn not caused by Displacement. — The sense of 
weight or bearing down in the pelvis is one as to which there 
would, from its nature, seem to be no doubt as to its origin being 
in displacement. It gives the patient the idea that the womb is 
bearing with unusual weight on unusual places, viz., the peri- 
neum, the rectum, or the bladder ; and yet, in a great many in- 
stances, we will fail, I think, to detect any deviation from the 
natural position of that organ, and as soon as the inflammation is 
cured the symptom vanishes, without any treatment being directed 
with reference to displacement. Plow can we account for this 
symptom ? I think its explanation may be found in the fact that 
the pelvic organs, on account of the inflamed condition of the uterus, 
and the general pelvic vascular turgescence, are unusually sensi- 
tive, and receive painful impressions from contact, which, in the 
absence of these conditions, would have no effect in causing incon- 
venience of any kind. I also think that moderate prolapse, re- 
troversion, or other displacement, when unattended by congestion 
or inflammation, may exist for a long time, without giving rise to 
any disagreeable sensation whatever. When the uterus is slightly 
displaced, with considerable pain and sense of weight accompany- 
ing this condition, the displacement is commonly considered to be 
the cause of the distress. When, however, the uterus occupies a 



LOCAL SYMPTOMS. 157 

normal position, and a sense of weight and pain still exist, they 
are regarded by most practitioners as the results of an "irritable 
uterus." That the uterus is sensitive, "irritable," if the term 
suits better, there is no doubt; but that it is ever so, without con- 
gestion or inflammation, I do not believe. 

Severity of Suffering not commensurate with Amount of Dis- 
ease. — The great error in the estimate of the importance of ute- 
rine inflammation, is in endeavoring to measure the amount of in- 
flammation by the severity of suffering ; in assuming, that because 
the woman suffers a great deal there must necessarily be exten- 
sive inflammation or ulceration. I believe I have seen more ner- 
vous prostration, more keen suffering, and have heard louder com- 
plaints from a small amount of endocervicitis, than from exten- 
sive and obvious external ulceration. Pelvic congestion and in- 
creased sensitiveness of the viscera contained in the pelvic cavity, 
caused by a small amount of persistent inflammation in the neck 
of the uterus, calls into action, in an exaggerated and intensified 
form, all the sympathies which are excited by the uterus in its 
physiologically congested condition, and its persistence wears the 
more upon the general organism, on account of the increased sen- 
sitiveness produced from day to day, by virtue of its chronicity 
alone. It is anticipating what I shall say in the chapter on Prog- 
nosis, to state that endocervicitis is not only more difficult to cure, 
but more destructive to the health and happiness of the patient, 
than inflammation and ulceration external to the os. Indeed, we 
often find cases of extensive ulceration very apparent through 
the speculum, and consequently entirely unmistakable to the most 
careless observer, which produces less inconvenience than an 
amount of endocervicitis so small as to escape the attention of 
any but an experienced gynecologist. The fact is perplexing, 
but the knowledge of it will cause a proper appreciation of what 
is apparently a trifling matter. 

Effects on the Functions of the Uterus. — Having given the fore- 
going sketch of the general and local symptoms of ulceration and 
inflammation of the neck of the uterus, I purpose to glance at the 
effects produced on the functional action of that organ. The first 
function assumed by the uterus and the last to continue is men- 
struation. It becomes a matter of interest to the physician to 
ascertain the cause of deviations in a function so persistent, so 



158 CHRONIC INFLAMMATION OF THE UTEEUS AND CERVIX. 

general, and so important to the health of woman. As inflamma- 
tion is the cause of injurious and even destructive tissual changes, 
and of functional aberration in the vital organs much more fre- 
quently than any other pathological condition, so I think that the 
functional aberrations of the uterus depend much more frequently 
upon inflammation than on any other one cause. 

Pain during Menstruation. — Pain during menstruation is not 
necessarily attended by deviation from the normal monthly flow. 
That there are varieties of dysmenorrhoea or painful menstrua- 
tion, with unusual quantities and extraordinary kinds of dis- 
charge, is true; but, in many instances, the discharge, though 
accompanied with pain, is right as to its character and quantity. 

Kind of Pain attendant upon Uterine Inflammation. — The 
kind of pain attendant upon uterine inflammation is, for the most 
part, the sa'me in quality but varying in intensity. It is a con- 
tinuous sore pain, with heat in the parts, so slight as to give the 
patient very little inconvenience, and it varies from this to pain 
of considerable severity. The pain is at times sufficient to cause 
the patient to keep her bed for several days, and sometimes for 
the whole period of the menstrual flow ; occasionally it amounts 
to agony, prostrating the patient by a paroxysm of pain, which 
may last a few hours or even several days. 

Cramping Pain. — Instead of this continuous sort of pain of 
varying intensity and duration, there are less frequently painful 
throes, "coming and going,'' like labor-pains or after-pains. This 
kind of pain is often mistaken for colic. They are often very 
severe, and may last a few. hours or several days. They may 
depend on some substance contained in the uterus, as shreds or 
membranes of fibrous exudation, and cease at their expulsion. 
But more often no such cause can be discovered in the evacua- 
tions ; nothing can be found but fluid blood or coagula evidently 
formed in the vagina. In other cases, the os internum uteri is 
small, and does not readily admit the passage of the uterine 
sound. 

Effects of Partial Closure of Os Uteri on Menstruation. — Many 
practitioners believe that this condition of the os internum, by 
preventing the ready flow of the blood, causes it to accumulate 
until the quantity is sufficient to arouse expulsive efforts for its 



LOCAL SYMPTOMS. 159 

extrusion. In a large majority of cases of painful menstruation 
I have had the opportunity of observing there was no coaptation ; 
and in several of the worst cases I have met with, the os internum 
allowed the sound to pass with so much freedom that I could not 
distinguish its locality. It is also true that in many cases in which 
the os externum was not larger than a small pin-hole, the patients 
menstruated without any pain whatever. I do not wish to assert 
that painful menstruation does not occur as the effect of any other 
cause than inflammation, though my conviction is, that inflamma- 
tion is its most frequent cause. The pain may occur at any time 
during the menstrual flow, and before and after it. Not unfre- 
quently a paroxysm of severe pain, lasting several hours or a day, 
warns the patient of the approach of the discharge ; and subsides 
suddenly and completely, or gradually and incompletely, as soon 
as the discharge is fairly established. Frequently the pain con- 
tinues during the whole time of menstruation, beginning shortly 
before or synchronous with the discharge, and subsiding with it, 
though in occasional cases it continues after it. We sometimes 
meet with patients who begin to menstruate without any suffer- 
ing, but who have pain during the flow, or after its discontinu- 
ance. I think that a majority of patients affected with uterine 
disease have some pain during menstruation : but there are some 
who have none whatever, and pass through their period with little 
or no suffering. (See Dysmenorrhea.) 

Manner of the Flow modified by Inflammation. — The manner 
of the flow is often modified. Instead of the continuous flow com- 
mencing moderately, gradually increasing, and then as gradually 
declining, every manner of deviation almost may exist. With 
some the discharge begins naturally, increases very rapidly, until 
at the end of twenty-four or thirty-six hours an average amount 
is lost ; and then the discharge suddenly declines and ceases, or 
continues in very moderate quantity for a time longer, and grad- 
ually or suddenly stops. With others the flow may begin and 
proceed naturally for a day or two, cease for one or two days, and 
then reappear and flow freely for a sufficient time. When men- 
struation proceeds in this way, it is generally attended with pain. 
These two varieties are more frequent than any other. 

Duration of the Flow. — The duration of the flow may not be 
affected by it. The flow may continue three weeks or the whole 



160 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

month. This, however, is not frequent. It does not much affect 
the periodicity of return, of menstrual congestion, and of effort ; 
but it is not unusually the case that we cannot distinguish the dis- 
charge which attends ovulation from the hemorrhage which pro- 
ceeds from an ulcerated surface, as hemorrhagic congestion is so 
constantly present. We often meet with patients who are so con- 
fused by the frequent irregular returns of uterine hemorrhage, 
that they lose all reckoning as to the time for the menstrual re- 
turn. Occasionally, continuous hemorrhage is present. The most 
frequent deviation from regularity in periodicity of the menstrua- 
tion consists in a slight anticipation of the time of its return. 

Menorrhagia. — Menorrhagia or hemorrhage at the menstrual 
period is not an unusual functional deviation. The hemorrhage 
is often very considerable, and continues after the usual period 
has passed by. The flooding is usually greater while the patient 
is in an erect posture, and it is greatly moderated by recumbency. 
Occasionally, however, it is not moderated by this means. It 
would seem probable, a priori, that monorrhagia would be the 
rule with patients affected with uterine inflammation, but such is 
not the case. I am not sure that even a majority of patients 
have it. 

Menorrhagia frequent in Cervicitis.— 1 have observed that mo- 
norrhagia occurs much more frequently in patients in whom the 
inflammation occupies the cavity of the neck ; this also is the case 
with painful menstruation. All cases in which there has been 
either great pain or hemorrhage, or both, for they are frequently 
coexistent, have been, in my observation, cases in which endocer- 
vicitis is the principal disease. Menorrhagia is not always the 
result of inflammation of the uterus, though inflammation is its 
most frequent cause ; and in such cases it cannot be cured with- 
out first curing the inflammation. (See Menorrhagia.) 

Amenorrhoea sometimes Results. — Amenorrhea is the least fre- 
quent of menstrual deviations as the effect of inflammation in the 
cervix uteri; but this inflammation is frequently the cause of 
scanty menstruation. It is curious to notice the manner in which 
this scantiness occurs. It seems to come on after the inflamma- 
tion has lasted for a considerable time, and is almost always asso- 
ciated with sterility. In cases I have watched for some time, I 
have been induced to believe that the organ was atrophied and 



LOCAL SYMPTOMS. 161 

rendered less vascular and erectile ; probably on account of a 
deposition of fibrine throughout the general structures of the ute- 
rus. I have not been able to verify my opinion in any case by 
dissection. The scantiness is sometimes attended with irregu- 
larity, which consists in postponement or lengthened intervals. 
I treated one patient for endocervicitis in whom the uterus did 
not appear to be, as far as I could measure it per vagina m, more 
than one inch and a half in length, and correspondingly small in 
the other dimensions. This patient would menstruate sometimes 
only a day every month, and discharge but half an ounce of blood 
each time, and occasionally the discharge would not return for 
five, six, and even nine months. In early life her menses had 
been regular in quantity, quality, and times, and unattended with 
pain. She was barren, having never conceived, as far as she was 
aware. She dated the beginning of her disease from vaginitis 
during an attack of fever, which occurred two or three months 
after marriage. (See Amenorrhoea.) 

Function of Generation affected by it. — The great function for 
which the uterus was formed, that of generation, seems very fre- 
quently to be disturbed by inflammation of the neck of the ute- 
rus. Some practitioners think, because a woman bears children 
with frequency, the uterus cannot be much diseased. This is un- 
questionably a mistake. I have known many women with exten- 
sive ulceration bear children very frequently. Conception may 
be entirely prevented by inflammation, or gestation may be ar- 
rested by miscarriage, or labor may be rendered difficult by it. 
It has already been stated that many women will bear children, 
having at the same time very considerable disease of the uterus, 
but there is always great liability to embarrassment of the func- 
tion in such cases. There is no doubt that many cases of ster- 
ility depend wholly upon inflammatory action about the neck. 

Sterility. — Sterility is attended by different circumstances. 
Some women are sterile their whole lifetime ; others, after having 
borne children to the full period and giving birth to them, become 
sterile for years, or for the whole of their subsequent life ; others 
again become pregnant soon after marriage, miscarry at an early 
period, and never again conceive. In most cases of sterility which 
I have had the opportunity of examining, I have invariably found 
evidence of inflammation in the cervical cavity. Very often the 

11 



162 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

inflammation is confined to this cavity. The history of these 
cases showed that ulceration and inflammation had existed from 
1>he time of menstruation ; these were cases in which conception 
had never taken place. In cases of sterility in which the women 
have become sterile after having once borne children, ulceration 
is usually situated around the os, extending upwards into the 
cavity of the neck. This is almost certain to be the case if the 
woman has borne several children. When the patient has mis- 
carried but once, there is not likely to be external inflammation 
to any great extent ; but if there have been several abortions, the 
ulceration is apt to creep out and manifest itself upon the labia 
uteri, and sometimes becomes very extensive. Although the fore- 
going statements with reference to the position and extent of 
ulceration in sterility will generally be found to correspond with 
the appearances, yet we must not be surprised to find pretty ex- 
tensive ulceration external to the os uteri in the originally ster- 
ile patient ; and in those who have borne children and become 
sterile afterwards, we shall sometimes find no external ulceration. 
The result of my observation is, that when sterility originates in 
uterine inflammation it is in that form of it known as endocer- 
vicitis. Sterility is oftener associated with the condition and 
quality of the leucorrhoeal production than on any apparent inca- 
pacity of the uterus. In many of these cases the secretions 
from the vagina are very abundant and intensely acid, so as to 
produce irritation of the external organs. Although the semen 
is diluted and defended from the influence of acid vaginal secre- 
tions by mucus of alkaline reaction, yet when these vaginal secre- 
tions are abundant and possess strong chemical qualities, they may 
destroy the vitalizing influence of the seminal fluid, and thus pre- 
vent fructification. Or the very thick, tenacious, albuminous fluid 
which sometimes plugs up the os uteri and whole cervical cavity, 
may prevent the ingress of the spermatozoa, which, by their inde- 
pendent motion, according to present belief, penetrate the uterus, 
meet the ovum somewhere on its passage to the os uteri, and pro- 
duce their fructifying influence upon it ; and thus is precluded the 
possibility of effective insemination. 

Abortion.-^ But conception may readily occur and pregnancy be 
complete, and after gestation has continued for a certain time 
abortion may take place. Abortion is a very frequent effect of 



LOCAL SYMPTOMS. 163 

inflammation and ulceration of the os and cervix uteri. The seat 
of inflammation or ulceration which most frequently induces it, is 
inside the cervical cavity. We find some patients who have 
aborted very frequently and never had a full term child ; others, 
who have had one or more children, but who miscarry every preg- 
nancy afterward ; and again, others who miscarry frequently and 
occasionally go to full term. It is not strange that miscarriages 
should result from this cause ; d priori, miscarriage might be re- 
garded as its necessary effect. Many patients bear children at 
term who labor under severe ulceration, and who are prostrated 
by the constitutional sympathies accompanying pregnancy. 

Conditions of the Uterus in Abortion. — Two general conditions 
of the uterus exist as the effect of the cervical inflammation, and 
are probably the proximate causes of abortion, viz., congestion or 
arterial injection of sufficient strength to cause hemorrhage ; and, 
perhaps, by means of insinuation of the clots, separation of the 
placenta, or irritability of such a nature that contraction and ex- 
pulsion follow conception ; or, perhaps, increased sensitiveness of 
the mucous membrane may increase its excito-reflex influence so 
as to arouse uterine contraction, and thus cause the foetus and 
membranes to be expelled. When abortion is caused by conges- 
tion, it is apt to be ushered in by hemorrhage. The hemorrhage, 
after continuing for a varied length of time, from a few hours to 
several days, is followed by uterine contractions. When abortion 
is the result of increased irritability, the first symptom is contrac- 
tion, with the paroxysmal pains attendant upon it. This continues 
for a time, when hemorrhage and expulsion succeed. When abor- 
tion occurs once, it is very likely to recur in every subsequent 
pregnancy about the same time until the disease is cured upon 
which the abortion depends. While abortion is very likely to re- 
cur in the congestive or hemorrhagic variety, it is generally not 
so exact in the time of recurrence. This variety, however, takes 
place more frequently at the time when the monthly congestion is 
present, while the other is independent of such influence. The 
probability is, that in the congestive variety the foetus perishes 
before expulsive efforts arise ; while in the other the foetus is not 
affected until the contractions have continued long enough to par- 
tially separate the placental attachments. Whatever doubt, how- 
ever, may be cast upon all this, there can be no question as to the 



164 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

injurious effect produced upon gestation by ulceration or inflam- 
mation of the cervix uteri. Mr. Whitehead, of Manchester, Eng- 
land, has written a book, full of information, almost solely to 
illustrate this consequence of uterine inflammation. 

Effect upon Labor. — The effect which inflammation of the os 
and cervix uteri exerts upon labor is not so apparent as upon the 
progress of gestation. Although I have watched patients whom I 
knew to be laboring under inflammation of the neck of the uterus 
in parturition, I have not been able to perceive any increase in 
suffering or tediousness. 

Even when induration and hypertrophy were both of several 
years' standing, no ill effects from them, so far as I could see, at- 
tended labor either at full term or prematurely. I have observed 
cases of abortion occurring in such patients quite as readily and 
without more troublesome symptoms than in one whose uterus was 
healthy. The general tissual changes going on in the uterus would 
lead us to expect this in advanced pregnancy, but I confess to 
some astonishment at having seen kindly, rapid, and complete dila- 
tation in abortion at the early periods. It is equally singular to 
see the return of the induration after the involution of the uterus 
is fairly completed. One would suppose that the softening accom- 
panying pregnancy would be permanent, and this is the case with 
indurations of recent date. I have not observed in such cases 
that the abortions were attended with more hemorrhage, or were 
more tedious or painful than when they occur as the result of some 
transient cause. 

Effects upon the Post-partum Condition. — Of its effects upon 
the childbed, or post-partum condition, a favorable opinion cannot 
be given from my observation. A good getting up is not to be 
expected with much confidence in patients affected with uterine 
disease. The most common effects in childbed is retardation of 
the processes of involution. The congestion consequent upon 
labor is protracted, the uterus remains larger and more sensitive 
than is usual, so that instead of the organ recurring to its primi- 
tive dimensions and susceptibility in one month, two or more may 
be required. The lochia, instead of subsiding in fourteen or 
twenty-one days, continues for weeks, or even months, after it 
should have subsided ; and when it goes off, it is apt to merge im- 
perceptibly into leucorrhoea, which becomes pesistent. Inability 



LOCAL SYMPTOMS. 165 

to walk or stand without great distress is the effect of the size 
and sensitiveness of the organ. A sense of bearing down, or of 
weight in the pelvis, pain in the sacrum, down the sciatic nerve or 
in the hip, harass the patient greatly, and these symptoms pass 
off so slowly that she is kept in bed an unusual length of time. 
Acute metritis not unfrequently supervenes, or acute inflammation 
of the cellular tissue at the side of the uterus. Phlebitis, pyaemia, 
and phlegmasia dolens are more likely to arise in patients who 
have chronic inflammation of the cervix. 

On the other hand, it is a fact that these subsequent acute in- 
flammations sometimes operate very favorably upon the cervical 
inflammations. Instances are not uncommon of patients being 
entirely cured of ulceration by the effects of gestation and labor 
upon the tissue of the neck and its mucous membrane. We are to 
hope for this favorable result only as a remote probability, because, 
as already stated, the condition of the parts is generally left in 
statu quo, or, if any difference is perceptible, it consists in an ag- 
gravation of the disease, and the patients get up from childbed 
rather worse than better. 



CHAPTER XII. 

CHRONIC INFLAMMATION OF THE UTERUS AND CERYIX. 

ETIOLOGY. 

Sexual Indulgence. — The unnatural social habits of woman, and 
the circumstances which surround her, render her extremely sus- 
ceptible to uterine disease. Coition, indulged in by the lower 
animals only for the purposes of generation, and periodically, at 
long intervals, is resorted to by man as the most common indul- 
gence of his lower nature. The continued and extreme excite- 
ment in the sexual system ruins many of both sexes, but it pro- 
duces the most disastrous effects upon women for obvious physio- 
logical reasons. 

Improper Reading. — Less powerful but still efficient sexual ex- 
citement is found in the influence of lascivious books, so generally 
read by the young, as well as in the nature of the associations con- 
nected with most of the amusements of society. 

All this is aided by heated rooms, stimulating diet, improper 
clothing, &c. At or near the periods of menstrual congestion 
these excitements operate with much more efficiency than at any 
other time. 

Cold. — During the menstrual congestion, the application of cold 
to a large portion of the surface is also a fruitful source of uterine 
inflammation in very young girls. 

Constipation. — Chronic and obstinate constipation keeps up a 
predisposing uterine congestion, and I have long since been led to 
regard continued constipation as a condition the most deleterious 
to female health. 

Standing. — Constant standing also produces much evil ; it is 
much worse than walking, or even than going up and down stairs. 

Abdominal Supporters, Pessaries, $c. — Pressure upon the ab- 
domen by miscalled uterine supporters, the improper use of pessa- 
ries, sponges, &c, may be enumerated as causes in certain cases 



ETIOLOGY. 167 

of uterine inflammation. There can be no doubt, also, that pro- 
lapse of the uterus, when considerable, and other displacements, 
are sometimes the cause of inflammation of that organ. This, 
however, is a rare occurrence, as I think displacements are much 
more frequently the effect than the cause. Circumstances occur 
which may mislead us, if we are not careful, as to the proper rela- 
tion between displacement and inflammation. 

Severe Exertion, Jolts, £c. — We not unfrequently meet w T ith 
patients who tell us that they were "perfectly well" up to the 
time of some severe exertion, jolt, or lift, when suddenly they 
felt something give way in the lower part of the abdomen suc- 
ceeded by pain in the back, hips, loins, groin, accompanied by a 
sense of prolapse and weight upon the perineum. Soreness and 
great permanent inconvenience persist, thereafter, until the case 
becomes chronic. In such cases, the patient dates the beginning, 
not only of her trouble but her disease, from the strain or jolt, and 
believes it to be the whole cause of her disease. A critical inquiry 
into the history of the case will convince us that inflammation had 
.preceded the accident, and that the uterus was probably rendered 
susceptible of the sudden depression by its increased size and 
weight. However this may be, the inflammatian is greatly aggra- 
vated, if not originated by the circumstance. 

Hemorrhoids. — The turgidity of the pelvic vessels, kept up by 
hemorrhoids, prolapse of the rectum, vagina, or bladder, or inflam- 
mation of any of these organs, must contribute largely to swell the 
number of uterine cases. 

Pregnancy. — Although pregnancy is a physiological condition, 
and, in the nature of things, ought not to even predispose to dis- 
ease of the uterus, recent investigation seems to , indicate it as a 
prolific cause of ulceration. Dr. Cazeaux and other French ob- 
stetricians have examined a large number of cases of pregnancy, 
with a view to determine the frequency of ulceration in this con- 
dition ; and having found ulceration almost always present they 
have determined that the leucorrhoea of pregnancy caused ulcera- 
tion of the uterine mucous membrane. As well might we expect 
to see ulceration of the bladder in consequence of diabetes mellitus, 
or ulceration of the skin in diaphoresis. Inflammation, undoubt- 
edly, has the effect in this case, as in all others, of giving rise to 
the profuse and perverse secretion of mucus as well as the ulcera- 



168 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

tion. There is no doubt but that, in consequence of the depen- 
dent position of the uterus in its relations to the vascular system, 
it is more liable to congestions of both a transient and persistent 
character than any other viscus, not even excepting the rectum. 
These congestions are the predisposing conditions of inflamma- 
tions generally, and if they are persistent and long continued, ex- 
cite as well as predispose to inflammations. Constipation, stand- 
ing on the feet for a long time, tight dressing, &c, act by impeding 
the upward tendency of the blood, causing it to leave the pelvis 
tardily, and thus keep hypersemia in the uterine vessels until or- 
ganic disease occurs. I cannot but believe that anything which 
will keep up these congestions for a sufficient time will bring about 
inflammation of the uterus in some part. 

Abortions. — Abortions are both the cause and effect of inflam- 
mations of the uterus. It is unnecessary to point out the delete- 
rious effects of abortions produced by violence. 

All the circumstances exist that are required. The violence is 
nearly always sufficient of itself at once to give rise to more or 
less acute disease. In cases occurring from other causes than in- 
tentional or accidental violence, there are many efficient causes of 
congestion and inflammation. Probably one cause not usually 
thought of, is the too early assumption of the erect posture. 

Bad Management after. — Being nothing but an abortion at an 
early period, it is not considered important by the physician .that 
the patient keep the horizontal position; the patient sits up, walks 
about, &c, and the congestion existing continues sufficiently long 
to produce inflammation. Now, I think it is quite as necessary 
for the patient to remain quiet in bed, until involution is well ad- 
vanced, in cases of abortion, as in labor at full term. Many of 
the conditions inducing inflammation in cases of abortion are the 
same as arise in parturition. I shall, therefore, speak of them 
under that head, and the intelligent reader will at once perceive 
them as they are brought forward. 

Labor. — The uterus, at the time of labor, is predisposed to vas- 
cular disease, on account of its extremely vascular condition ; when 
labor comes on the excitement is tumultuously increased, the ner- 
vous susceptibilities are enhanced, while the forcible contraction 
of the muscular part of its composition greatly adds to its excita- 
tion. When we remember the powerful compression of the os and 



ETIOLOGY. 169 

neck by the child's head in passing through them, and even the 
frequent lacerations to which the mouth is subjected, it is aston- 
ishing that nature is competent, under the circumstances, to so 
completely restore so many parturient women to their former con- 
dition of perfect uterine health. 

Decomposition of Productions of Labor. — In addition to all 
these, however, there is generally more or less decomposition of 
organic matter in the vagina, near the os and neck, giving rise to 
irritant products which, without proper cleanliness, might remain 
long enough in contact with the highly sensitive parts to cause" in- 
flammation. I know that nature should, and may, in most in- 
stances, safely be trusted to repair all the damage done in these 
ways when other circumstances are favorable; but these favorable 
circumstances are often wanting. The erect posture is too early 
assumed in many women, on account of their necessitous condi- 
tion, or thoughtlessness and ignorance. This prolongs congestion 
of the dependent uterus, arrests or retards involution, and excites 
the uterus to inflammation ; this inflammation is often prolonged 
by the continuance of the same cause until it becomes a fixed con- 
dition. The number of circumstances which cause and increase 
inflammation, in cases of parturition particularly, will be seen and 
understood without dwelling further upon them. We should 
remember them, and give our best care to patients passing 
through the conditions of the lying-in month, and thus avoid much 
suffering. 

Vaginitis. — Inflammation originating in the vagina often spreads 
to the neck of the uterus, and occupies its mucous membrane ex- 
ternally, passes into the cavity of the cervix, and often, I think, 
to the cavity of the body of the uterus. 

Gonorrhoea. — Gonorrhoeal vaginitis is very prone to do so, and 
if not arrested while yet in the vagina, and that soon after its 
commencement, the neck of the uterus is seldom left without per- 
manent damage; and after gonorrhoeal vaginitis is cured, it is fre- 
quently the case that the cavity of the neck is left inflamed. This 
may, and I think generally does, become chronic, unless removed 
by appropriate applications made directly to the membrane. 

There is reason, too, for believing that the vaginal inflammation, 
in which profuse leucorrhceal discharges originate, arising from 
other than contagious causes, may pursue the same upward course, 



170 CHRONIC INFLAMMATION OP THE UTERUS AND CERVIX. 

and leave behind the same grave chronic difficulties. It is well 
known that vaginal discharges are sometimes the result of general 
conditions, such as the scrofulous, for instance, so that we may 
have scrofulous vaginitis, and this may spread to the mucous mem- 
brane of the genital canal. Vaginitis may also arise from im- 
moderate coition, masturbation, or the introduction of foreign 
bodies from perverse habits. What I have said above of the effect 
of vaginitis in causing cervical inflammation of the uterus, was in- 
tended to apply more particularly to this disease occurring in 
adults ; but there is another condition under which it occurs, that 
I think has escaped the attention of medical men, or at least has 
not attracted sufficient notice, viz., the vaginitis of children. 

Vaginitis of Children. — I think I have observed several in- 
stances in which, before the appearance of the menses, the cavity 
of the cervix must have been affected with inflammation extending 
from the vagina. Indeed, if the history of patients who very 
early commence to complain of signs of inflammation of the cervix 
be properly traced, it will be nearly, if not always, found that 
they were to some extent the subjects of leucorrhoeal discharge 
during their childhood. The kind and locality of the disease aris- 
ing from infantile vaginitis is almost peculiar. It is situated in- 
side the cavity of the neck, and if the os uteri is examined with 
the speculum, when the disease is not great there will be found 
but little, if any, unnatural appearance, save the issuing of muco- 
pus from it. The os is often contracted in size ; it is very seldom 
enlarged. 

These young patients do not generally complain much of suffer- 
ing from their vaginal inflammation until the commencement of 
their menstrual visitation, when they have severe pain at each 
time. The suffering ordinarily increases as the functional activity 
of the uterus increases, until the patient is a confirmed sufferer 
with dysmenorrhea or monorrhagia. At other times, instead of 
having much direct uterine suffering, the general nervous system 
is most affected, or the vascular or nutritive systems become 
seriously deranged at the period when the menses should appear. 
It is not the usual opinion, but I am, nevertheless, inclined to the 
belief that chlorosis and chorea are sometimes the effect of de- 
rangements thus produced. 



ETIOLOGY. 171 

The above short and imperfect sketch of the causes of inflam- 
mation of the mucous membrane of the uterus will give but an 
inadequate idea of the vast number of causes which produce the 
inflammation in question. There is no mucous cavity in the body 
that is subject to so many causes of intense excitement, arising 
from the nature of its functions, from its accidents and abuses, as 
is that of the cavity of the female genital canal. Hence it is not 
wonderful that this cavity is very much more frequently the seat 
of disease than any other mucous cavity in the human body. 



CHAPTER XIII. 

CHEONIC INFLAMMATION OF THE UTEKUS AND CEKVIX. 

PROGNOSIS. 

A just estimate of the chances of making a cure, or of sponta- 
neous recovery ; or, in other words, correct notions of the prog- 
nosis of a disease in any given case, has necessarily great influ- 
ence upon our treatment; and a truthful prediction of the progress 
of a case, or of its ultimate result, has an important relation to 
our reputation and to the confidence of our patient. It is espec- 
ially important to be able to give a reliable prognosis in cases in 
which the profession as well as the patients are not perfectly sat- 
isfied about the pathology and therapeutics in reference to them. 
Too unfavorable an opinion discourages our patient, and precludes 
us from having a fair opportunity of exercising our efforts ; too 
favorable an opinion, one not justifiable by the result, brings dis- 
appointment to the patient, injures the reputation of the prac- 
titioner and the profession, and is also apt to influence improperly 
the inexperienced medical man against the treatment adopted. 
The general principle that should govern our prognosis is tem- 
perance. We should temperately encourage our patient, if we 
can conscientiously do so, and if our judgment will not allow us 
to do this, we should express, temperately and cautiously, an un- 
favorable prognosis ; and hope should never be extinguished until 
a patient is moribund. Too many good reasons will suggest 
themselves for the last course to require any argument in support 
of it. What I have said of a guarded prognosis, and the necessity 
of not giving a sweeping and absolute opinion, seems to me pecu- 
liarly applicable to the disease of which I am now treating. 
Physicians have not all been convinced of the propriety of treat- 
ing uterine diseases with the speculum ; a large number are en- 
tirely, and conscientiously, opposed to it. They are made so, un- 
doubtedly, by the failure of local treatment to fulfil the hope 



PROGNOSIS. 173 

originated by its most ardent advocates. It does not do what they 
are told it will do ; it certainly does not in all cases. The only 
grave error I think committed by that benefactor of womankind, 
Dr. Bennett, in his work on the Unimpregnated Uterus, is that 
his book leads his readers to believe that he scarcely, if ever, fails 
to cure his cases. This is the impression made upon most phy- 
sicians who read his book. However true it may be, with refer- 
ence to the practice of so able a master, I think it would be an 
unjustifiable expectation on the part of the profession at large. 
From what I have heard and read of the opposition of medical 
men to local treatment in uterine disease, I think this unrealized 
expectation of success from local treatment, is one of the main 
causes of it. Upon trial, medical practitioners become disap- 
pointed with the results as they were led to expect them, and 
abandon the plan as a failure. While I cannot coincide with Dr. 
Bennett as to the almost universal success of local treatment for 
uterine inflammation, I am of the opinion that it is greatly su- 
perior to any other with which I am acquainted. Prognosis must 
depend for its reliability, to some extent at least, upon a correct 
and complete diagnosis of the whole condition of the patient. 

Uncomplicated Case Favorable. — The probability of recovery 
of health will depend upon the absence of any important general 
diseases in conjunction with the local. We should remember that 
the patient aims at recovery of health, instead of merely the cure 
of any one part of the ailments. An important matter is to de- 
termine the pelvic complications, if any exist, and how far they 
are curable, before we pronounce a prognosis. 

Prognosis without Treatment. — What is likely to be the progress 
and result of the disease when allowed to go on without interfer- 
ence ? Generally, it will go on from bad to worse. This is par- 
ticularly the case with the childbearing woman ; it is almost 
equally true of the menstruating unmarried woman. In the lat- 
ter, however, if she avoids the causes which aggravate it, she may 
not get worse ; but if her situation, or her inclination, subjects her 
to the aggravating causes, she will also become worse. Not un- 
frequently the patient recovers after the " change of life" takes 
place. The cessation of the menstrual congestions, if other things 
are favorable, seems to determine a gradual recovery. This I 
fear, however, is far from being as frequently the case as we 



174 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

might suppose from reading, and judging physiologically of the 
matter. Indeed, some of the most obstinate cases I have met 
with were patients in whom the disease had outlasted the change 
of life. 

Not often directly Fatah — Notwithstanding the tendency of the 
disease to get worse during the whole menstrual life of the patient, 
and to subside only with the subsidence of uterine activity, it sel- 
dom proves fatal directly. Nor do the most common and imme- 
diate effects of it proceed to a fatal extent. The debility, the im- 
perfect or perverted hsematosis or the nervous energy, seldom 
becomes so great as to be the immediate cause of death. This, 
however, sometimes does occur, and we should indulge a false secu- 
rity to suppose that our patient could not thus die. I think I have 
seen more than one instance of death thus resulting. The nervous 
and muscular centres very rarely become so influenced by per- 
verted innervation and haematosis as to assume dangerous or even 
fatal complicating conditions. 

Indirectly Fatal.— As very correctly stated by Dr. Bennett, 
such an unnatural condition of the nervous system and blood is 
engendered by the disease as to destroy the capacity of the patient 
to resist or ward off the attacks of the acute diseases to which she 
may be exposed, or the chronic ones for which she may inherit a 
strong predisposition. It is difficult, also, to resist the belief, 
although I have not verified it by observation, that puerperal 
fevers and post-partum affections are more likely to occur and as- 
sume a dangerous or fatal state in patients affected with chronic 
uterine disease. I need hardly mention the increased hazard to 
married women from abortions, and the diseases intercurrent with 
them. 

Prognosis in different Varieties. — There is some difference, 
other things being equal, in the gravity or seriousness of different 
varieties of inflammation. Some produce much worse effects upon 
the constitution, are more obstinate and protracted in their dura- 
tion, and even resist treatment with greater persistence than others. 
When the inflammation is confined to the mucous membrane out- 
side the os uteri, the prognosis is most favorable ; if the inflamma- 
tion exist in the mucous membrane of the cavity of the cervical 
canal, it will be more obstinate and difficult to eradicate; and some 
of these cases are exceedingly so. In the class of cases in which 



PROGNOSIS. 175 

the inflammation has extended to the submucous tissue, the prog- 
nosis, so far as a perfect cure is concerned, is unfavorable ; it 
becomes especially unfavorable when the inflammation has lasted 
so long as to materially alter the shape, size, and consistency, 
by deposition of fibrine, of the neck of the uterus. In these 
cases the inflammation is not all that has to be encountered, but 
the organic alteration must be corrected. This cannot always be 
perfectly done. If the neck of the uterus is indurated, enlarged, 
and nodulated, we can only partially restore the organ to its orig- 
inal softness, evenness, and size ; and to do this requires a long 
time, and patient and judicious management. 

Prognosis under Treatment. — In cases of uterine inflammation 
and ulceration in general, what is the prospect under properly 
conducted treatment ? The prospect of cure is comparatively 
favorable. I mean by this statement that, compared with other 
diseases which produce as much suffering, the prognosis, under 
proper treatment, is quite favorable. What the per cent, of cures 
would be if summed up, I could not say ; but it is large. A more 
circumstantial consideration of the prognosis I think would be 
profitable. With reference simply to recovery or death, the prog- 
nosis is favorable, because, even when a cure is not effected, as we 
have seen, it is not usually fatal. 

Can the Inflammation be always removed, and if removed, will 
the local symptoms always subside f — The local inflammation can 
nearly always be removed ; but with its removal, the local symp- 
toms do not always leave the patient. 

Will the several Symptoms always subside? — The inflammation, 
so far as we can see, may generally be removed ; but many of the 
symptoms, as the pain in the back, groin, or elsewhere, may per- 
sist, to the great discomfort of the patient. I have endeavored to 
show that many of the symptoms depend upon the congestion kept 
up in the whole of the pelvic organs ; and that these congestions 
are not unlike those produced by the menstrual molimen, and that 
this persistent congestion depends upon the presence of the inflam- 
mation in the cervix and os uteri. This congestion sometimes 
outlasts the inflammation, and thus keeps up some of the local 
symptoms. But by far the most frequent reason why the local 
symptoms do not subside, is the persistence of inflammation to 
some extent. This may be out of sight, and consequently undis- 



176 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

covered ; but if it is mucous inflammation, we may know that it 
is not cured while there is a superabundance of mucous secretions 
or vitiated mucus or pus in view. If it is submucous inflamma- 
tion which still exists, there will be unnatural tenderness when 
touched by the finger or instruments. This tenderness being un- 
natural, would indicate still some inflammation. 

How long will it take to cure the Inflammation f — In what 
length of time can we reasonably expect a cure of the local in- 
flammation ? No certain answer can be given from any mere ob- 
servation of the case in the beginning. From three to twelve 
months should be the latitude given in most instances. A shorter 
time than three months is uncommon ; and we might in many in- 
stances not reasonably expect a cure in twelve. In order to fulfil 
the expectations of the patient and of ourselves, we should take 
plenty of time, and we should not lead our patients positively to 
expect a removal of all the symptoms when the treatment has ter- 
minated ; for they sometimes subside so slowly that they continue 
many months after the treatment has ceased. The general or 
sympathetic symptoms sometimes become a sort of habit, and 
continue after the disease which called them into existence has 
been cured. This is particularly the case with the great degree 
of general nervousness which renders some patients miserable ; 
but in the great majority of cases they do subside very readily as 
the ulceration is cured. When they do not, judicious treatment 
directed to them will do more for them, after the ulceration is re- 
moved, and will almost invariably relieve the system of them. 
For the removal of these general symptoms, time is an item of 
the utmost importance, and we do not do justice to our own repu- 
tation or to the patient, by fixing the time too-positively in which 
relief may be expected. 

Prognosis influenced by Age of Patient. — The age of the pa- 
tient, I have thought, had a good deal to do with the readiness and 
completeness of recovery from all the troubles of uterine disease. 
Young women will recover quicker than the old ; the naturally ro- 
bust and active woman sooner than the delicate and inactive. If 
there is an hereditary predisposition to insanity, or any general 
nervous disease, there is great likelihood of its being excited into 
activity by uterine irritation ; and when once started, they are apt 
to assume a permanent and durable form. We should not, there- 



PROGNOSIS. 177 

fore, promise too much in patients whose general health has been 
long seriously affected, as it is impossible to predict the measure 
of benefit to be derived from a removal of the cause of the general 
affection in the cure of the local. 

Hoiv and ivhen does Relief come in Favorable Cases ? — But, in 
Cases in which relief from the general and local symptoms readily 
succeeds the treatment, there is considerable difference as to the 
mode in which the relief comes. In very many cases the patient 
experiences benefit from the beginning. In the first month she 
feels the cessation or a great amelioration of some of her symp- 
toms, generally of the local pains, and she continues to improve 
until entirely cured. In other instances, the symptoms are aggra- 
vated for several weeks, and there is no improvement until after 
the local treatment is discontinued ; again, relief does not follow 
for some months, and yet by judicious general management it is 
secured. In a great majority of cases, we may very plainly see 
the beneficial effect of our treatment, if not before, certainly by 
the time we have procured the complete resolution of the local 
disease. As I have before intimated, the general sympathetic ef- 
fects are sometimes kept up by local complications, and will sub- 
side only when they are removed. 

Will the Functions be Restored ? — An important part of prog- 
nosis, one in which our patient often feels a deep interest, is the 
determination of the prospect of restoring the functional derange- 
ments of the uterus. As it has been before stated, inflammation 
and ulceration of the cervix uteri often cause sterility. This con- 
dition occurs under two different sets of circumstances ; in one, the 
patient never conceives after marriage, and may remain sterile 
during her whole lifetime ; in the other, she conceives and miscar- 
ries, or even goes to full term of pregnancy for one or more times ; 
and then, as the inflammation and ulceration become established, 
she ceases to becom^ pregnant. Where the patient has been mar- 
ried for several years, and does not become pregnant, the cure of 
the disease is not generally followed by productiveness ; and when 
it is, it is usually after the lapse of a long time, sometimes amount- 
ing to several years. Although this is the most common condition 
of the functions, sometimes, after treatment, fertility is the imme- 
diate effect of a cure. I have noticed that patients who remain 
sterile in this way, usually have a very scanty menstruation ; and 

12 



178 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

we cannot reasonably hope that our patient will cease to be sterile 
when she is cured, if this very scanty menstruation is not, or can- 
not be corrected. I am inclined to think that in cases of this kind 
the ovaries are in some way, probably by chronic inflammation, 
also rendered unfit for their duties. Those who are restored to 
fertility by the cure of the inflammation, always, or nearly always, 
have a normal condition of the menstrual flow. 

Patients who have conceived and miscarried, or borne children, 
but become sterile, are usually cured of their sterility with the cure 
of the disease of the uterus. Yet repeated instances have come 
under my observation, where a miscarriage soon after marriage has 
resulted in permanent and incurable sterility. Almost all these 
cases were abortions induced by forcible means. The inflamma- 
tion seemed sufficiently intense to destroy the capacity of the 
uterus for lodgment of the foetus ; or, at any rate, to render that 
organ in some manner unfit for the discharge of its part of the 
function of generation. If a woman has had several miscarriages, 
or borne a number of children, and then becomes sterile, there is 
great reason to hope that she will at once become fruitful as soon 
as the inflammation is cured. This result will be the more likely 
if menstruation retains its natural characteristics. The habit of 
miscarrying is generally quite effectually broken up by the cure 
of the disease on which it depended, so that we may pretty confi- 
dently assure our patient that as soon as the inflammation is cured, 
pregnancy will go on uninterruptedly to the full term. We should, 
however, promise this only of future pregnancies ; as, according 
to my observation, a cure undertaken during the existence of this 
condition is not very promising, although we have good authority 
for making the attempt. I am not satisfied that the attempt is 
always best to be made, and generally wait until pregnancy is 
over, and even stop the treatment if I have begun. I could cite 
many cases corroborative of the statement that habitual abortion 
is cured by the relief of the inflammation. It will not be amiss 
to state the result of my observation as to restoration from the 
menstrual deviations which attend, and for the most part depend 
upon the diseased uterus. It may be stated that, generally, this 
restoration takes place, but it certainly does not always. I think 
different sorts of menstrual trouble are differently influenced by 
the cure of the inflammation. Scanty menstruation often remains 



PROGNOSIS. 179 

permanent after the cure of the diseased cervix, and much more 
frequently resists treatment than any other derangement. Where 
the menses have been wholly suppressed, we may hope for better 
results from judicious management. In fact, the stimulation of 
the uterus generally restores this function when absent on account 
of chronic inflammation, unless, as is sometimes the case, so much 
organic alteration has been brought about as to destroy, to some 
extent, the texture of the organ. Menorrhagia often continues 
with considerable obstinacy after all the disease of the cervix is 
removed; but it is nearly always much moderated, and quite fre- 
quently entirely cured, and ceases to trouble the patient before 
the inflammation has wholly disappeared. Where it is obstinate, 
it will nearly always be found to be the case that after the lapse 
of a few months it begins to improve, and after a while the men- 
strual discharge will not exceed the natural quantity. I think we 
may pretty confidently hope that by the exercise of a little patience 
we will cure this functional disorder of the uterus, where it has 
depended upon inflammation of the cervix. 

Dysmenorrhea, when dependent upon this cause, disappears 
often very readily under the influence of treatment directed to the 
cervix, but we should be careful to distinguish between it and that 
which depends upon other causes. Very commonly one of the first 
good effects of local treatment is to ameliorate the suffering during 
the menstrual discharge. This is often remarkably the case, the 
first menstrual effort being so much better as to astonish the 
patient and her friends. It would hardly be justifiable, however, 
to promise, generally, such ready relief; for sometimes this feature 
of the case remains quite obstinate, and causes the patient a great 
deal of suffering after the inflammation is entirely cured. 

Complicated with Phthisis. — In the course of my practice, it 
has occurred to me to have cases complicated with tuberculous 
disease of the lungs, and some of these patients have seemed to 
run down more rapidly after their recovery from the uterine dis- 
ease than before, on account of their softening and discharge. I 
have not had an opportunity to observe a sufficient number of such 
cases with that scrutiny so necessary to arrive at a correct con- 
clusion. It might be supposed that, on account of the derivative 
influence of the uterine disease, the consumption was kept in abey- 
ance by its continued existence. On the other hand, the debili- 



180 CHRONIC INFLAMMATION OF THE UTERUS AND CERVIX. 

tating effects upon the system at large, which it undoubtedly ex- 
erts, might with equal propriety be expected to co-operate in the 
general prostration. 

Throat Disease. — The frequent complication and the effects ex- 
erted by the one upon the other of throat affections, — pharyngitis 
and laryngitis, — and uterine affections, makes it a matter of in- 
terest to determine what, if any, is the effect upon the diseases of 
the throat, of curing ulceration of the cervix uteri. This may be 
regarded by most of my readers, and probably is, an irrelevant 
question in this connection, but I think careful attention to it will 
lead to a different way of thinking about it. I am persuaded that 
some, at least, of the chronic sore throats of this climate can be 
much more easily cured after the uterine complication is removed. 
Women often believe that there is an intimate connection between 
them, and hope that the cure of inflammation of the uterus will 
relieve the throat ; and I have seen cases in which I was almost 
ready to believe there was some encouragement for the opinion. 

Skin Diseases. — Psoriasis, lepra, and some other of the chronic 
forms of scaly eruptions, coexisting with inflammation of the 
cervix uteri, have been aggravated or ameliorated as the uterus 
grew better or worse ; when the uterus is better the eruption is 
worse, and the converse. I have noticed several cases in which 
this seemed to be unequivocally true ; and it is remarkably the 
case in two patients now under my observation. Without my 
speaking of it, they have both remarked it. If this observation 
should prove true on a large scale, it would indicate the extension, 
in a modified form, of this chronic inflammation to the mucous 
membranes, and afford us a valuable hint for the appropriate mode 
of managing a class of very obstinate cases. The above facts 
have an important and direct bearing upon our prognosis ; for, ac- 
cording to my experience, the cases attended with these chronic 
skin diseases are very obstinate and protracted. 

Cure remains Permanent. — When cervical uterine inflammations 
are once cured, are they likely to return ? It is a popular belief 
that these uterine diseases cannot be permanently cured ; that they 
will keep returning. This belief is, no doubt, supported by the 
fact that many of our patients are constantly laboring under the 
causes that originally produced the affection ; and, therefore, are 
likely to have them reproduced. Of course, patients thus situated 



PROGNOSIS. 181 

will have a return of the diseases, but where the causes can be 
avoided and the cure completed, there is no reason why they will 
not remain cured with as much certainty as any other disease sus- 
ceptible of perfect removal. I cannot refrain from here express- 
ing the opinion, however, that a large majority of the cases that 
thus thwart our hopes never are entirely cured, and I believe great 
discouragement arises from want of the experience necessary to 
decide when the disease is entirely removed. I have met a number 
of instances in which the practitioner supposed he had removed 
the inflammation, but the symptoms remained; where an examina- 
tion revealed a discharge of muco-pus from the mouth, showing in- 
flammation still remaining inside the neck, and discoverable only 
by the discharge. 



CHAPTER XIV. 

COMPLICATIONS OF INFLAMMATION OF CEEYIX. 

Complications. — Various and troublesome intra-pelvic complica- 
tions are often observed in connection with uterine disease. These 
complications for the most part arise during the existence, and 
generally as the effect, of the disease of the uterus ; they may, of 
course, also arise as independent affections. Notwithstanding the 
frequent secondary origin of these complications, after they have 
continued for a considerable length of time, some of them become 
permanent, and after the originating disease has subsided, they go 
on indefinitely if not cured. 

Vaginitis. — Probably the most common of them is vaginitis, in 
some form ; ordinarily in that of erythematous inflammation of the 
mucous membrane, which is indicated by an increased mucous dis- 
charge, some tenderness and heat. Instead of the inflammation 
being thus moderate, there may be copious muco-purulent dis- 
charge, great irritation, and so much tenderness as to render an 
instrumental examination very painful, and often unsatisfactory. 
Such severity of inflammation is apt to be of short duration, and 
dependent upon some superadded cause of the inflammation. The 
inflammation is usually more moderate and persistent, continuing 
more or less for weeks or months together. Another form of 
complicating vaginitis is eruptive, and, although not usual, it yet 
sometimes accompanies the simple variety. The eruption in the 
milder form is vesicular. Small vesicles appear somewhat thickly 
studding the inner surface of the labia, on the nympha, the mem- 
brane of the vestibule, and sometimes the cutaneous surface on 
the edges of the labia majora and the anterior edge of the peri- 
neum. This eruption is attended with great heat, or a burning 
sensation, and not unfrequently with intolerable itching. The ves- 
icles are not very thickly set upon the surface, but the latter is 
of a fiery red color. A greater or less amount of serous discharge 
keeps the parts wet and sticky. Almost always this mild erup- 



COMPLICATIONS OF INFLAMMATION OF CERVIX. 183 

tive variety is paroxysmal, and generally appears simultaneously 
with the commencement of the menstrual discharge, and has 
seemed to me to be dependent upon the acrid discharge accom- 
panying it, and the congestion present at such times. The erup- 
tive variety of vaginitis is sometimes much more severe in grade, 
and the vesicles are changed to pustules, and the accompanying 
inflammation much greater. Fortunately this is not nearly so 
common as the first two forms. Vaginitis sometimes has its origin, 
I have no doubt, in an extension of the mucous inflammation from 
the neck ; but frequently, I think, the inflammation is caused by 
the acrid irritating nature of the perverted secretions from the 
mucous membrane of the cervix, and by want of proper cleanli- 
ness. The vaginal inflammation, although exceedingly annoying 
to the patient, is otherwise of much less importance than some of 
the other complications. 

Urethral and Cystic Inflammation. — Urethral and cystic in- 
flammation also not unfrequently result from or accompany cervi- 
cal inflammation. It is not necessary to give their symptoms in 
detail. The main fact to which I desire to give expression is, that 
when there are symptoms of cystitis or urethritis, we should be 
watchful for the probable occurrence of inflammation of the blad- 
der and urethra, and be aware of the importance of giving atten- 
tion to them as complicating diseases. For I think I have seen 
indubitable instances of cystitis and urethritis which could be 
traced to this cause, continuing after the uterine disease was 
cured. When not properly attended to, they may induce nephri- 
tis. The inflammation of the neck no doubt directly induces in- 
flammation of the bladder, by reason of its immediate apposition 
to its walls; and while this inflammation ordinarily is of short 
duration, yet it sometimes becomes very persistent, and even per- 
manent. The attacks, when acute in grade, as they sometimes 
are, become extremely distressing, and absorb the whole attention 
of the patient, and demand the prompt interference of the medi- 
cal attendant. More commonly the grade of inflammation is mild, 
and confined to the mucous membrane of the organ. The scalding 
micturition, indicative of urethritis, is often distressing to a great 
degree, and is not unfrequently very persistent. This urethritis 
and cystitis I think are* caused by migrating inflammation from 
the vagina in some cases, and the inflammation probably goes on 



184 COMPLICATIONS OF INFLAMMATION OF CERVIX. 

through the ureters to the pelvis of the kidneys. When cystic 
inflammation is persistent and somewhat severe, it often passes for 
the disease. The symptoms of cervical inflammation of the uterus 
being overwhelmed and obscured by the more urgent and distress- 
ing vesical affections, it is not thought to be the origin of the 
trouble. Although the vesical symptoms, as before stated, may 
become urgent, and the inflammation assume an important promi- 
nence in the case, usually this complicating affection is slight, and 
manifested by very mild and transient symptoms. In this form, 
cystitis and urethritis are very common indeed. 

Cellulitis. — A more formidable, troublesome, and perplexing 
complication, however, is a chronic or subacute form of cellulitis, 
as it has been named by Prof. Simpson. It consists of inflamma- 
tion and suppuration of the cellular tissue contained in the dupli- 
cation of the peritoneum, at the side of the uterus. I think this 
is a frequent complication, and more frequent, according to my 
observation, than we are led to believe by any description I have 
ever met with. When it is present, it embarrasses our diagnosis, 
and should very materially modify our prognosis. I have met 
with instances in which it remained unnoticed, and exercised a 
very embarrassing effect upon the treatment and the progress of 
the case for a long time. This complication is important for two 
main reasons at least, viz., 1st, the great obstinacy with which in 
the chronic form it resists treatment ; and 2dly, from the fact 
that the pelvic or uterine symptoms do not subside while it lasts, 
even when the uterine disease is removed. It is likely to occur in 
two forms, differing considerably in intensity and duration, — the 
acute and the chronic. 

Acute Cellulitis. — In the acute form the symptoms are violent, 
and run their course somewhat rapidly. The patient, after some 
exposure, or more than ordinary exertion, experiences a great in- 
crease of pain in the pelvis ; it usually occurs on one side, and 
rigors supervene, which are succeeded by febrile reaction of high 
grade. The pain is constant, and often excruciatingly severe, 
of a tense and aching character. It is sometimes attended by 
paroxysmal exacerbation, but it is generally free from it. The 
fever, pain, and great soreness, continue from six to twenty days, 
or even longer. The fever gradually becomes more remittent, 
and finally intermittent, being terminated, or nearly so, every 






COMPLICATIONS OF INFLAMMATION OF CERVIX. 185 

night by copious perspirations. The pain continues, however, 
until it is relieved by a discharge of pus per vaginam, rectum, or 
urethrem. 

Suppuration in Cellular Tissue. — If the discharge is free and 
copious, immediate and almost complete relief follows ; if, as is. 
much more frequently the case, the discharge is small, the relief 
is only partial, and the patient lingers in a state of great suffering 
for weeks, and even months, before the discharge is completely 
effected, and the cavity of the abscess filled up. During the ex- 
istence of these acute symptoms, if we examine per vaginam with 
the finger, we will find the mucous membrane hot and exceedingly 
tender to the touch. 

Diagnosis of Cellulitis. — In seeking to ascertain the relation 
of the organs, the uterus generally will be discovered situated 
near one side of the pelvis, and fixed in its position, so that it 
cannot be easily moved in any direction ; or it may be in the 
middle of the pelvis, and a little lower down upon the perineum. 
When it is to one side, we may feel on each side of it solid tume- 
faction, filling up to a considerable extent, if not completely, the 
lateral and anterior portions of the pelvis; and if we press upon 
this hard and tumefied part, we shall cause great complaint of ten- 
derness. The patient will cry out with the pain produced by it. 
If the uterus is central in its position, the hardness, pain, and 
swelling will occupy one side of the pelvis, and while it will give 
the patient great pain to carry the finger up the side of the uterus, 
where this tumefaction is situated, on the other side there will be 
no tenderness. 

Extent of Cellulitis. — These inflammations invade the cellular 
tissue in the pelvis to a greater or less extent in different cases, 
and sometimes the infiltration is ,so great as almost wholly to fill 
up the cavity of the pelvis. In other cases there is only a very 
small amount of induration, not larger than the thumb. Now, 
attacks of the kind above described cannot deceive a careful prac- 
titioner ; but the milder and less pronounced variety may go un- 
noticed, unless we are watching for it. 

Chronic Cellulitis. — The patient in the milder form is seized 
with some increase of pain in the back or groin, or elsewhere 
about the pelvis, which lasts for three, four, or five days ; and 
after a discharge of very little pus, it subsides, and leaves the pa- 



186 COMPLICATIONS OF INFLAMMATION OF CERVIX. 

tient in her usual condition. This mild form may, and indeed often 
does, occur as an original condition, but much more frequently it 
follows at some distance of time an acute attack, such as I have 
above described. However this may be, it nearly always repre- 
sents a small nidus of chronic inflammation by the side of the neck 
of the uterus. The chronically inflamed cellular tissue in this re- 
gion is not so great in amount as to cause any febrile excitement, 
and in fact attracts but little attention, except when it is aggra- 
vated into the suppurative process from time to time. I have met 
with instances in which suppuration and discharge of pus from a 
small chronically inflamed point of cellular tissue had recurred 
every few weeks for twenty or more years. And it is often the 
case that patients having this inflammation will experience exacer- 
bations every month, before or after menstruation, and thus these 
attacks may pass for cases of dysmenorrhoea. The frequent dis- 
charges of pus with these slightly painful exacerbations should 
cause us to make an examination, when we may generally find a 
point of induration and tenderness. The results of the examina- 
tion will be most satisfactory at the time of the exacerbation, as 
the parts will be more tender and the swelling greater. 

It is not necessary for me here to go any further in the descrip- 
tion of this intra-pelvic abscess, as I only wish to call attention 
to the fact that it is not an unfrequent complication of uterine 
disease ; that the symptoms attending it very much resemble in- 
flammation of the neck of the uterus ; and that when it continues 
after the inflammation and ulceration of the neck are cured, the 
uterine symptoms do not subside as readily as when these last are 
not thus complicated. To the inexperienced practitioner it is a 
troublesome and perplexing complication, and if not particularly 
cautious, he is betrayed into an unjustifiable prognosis, if nothing 
worse. Intra-pelvic inflammations of this kind, although occasion- 
ally independent and uncomplicated, I think are much more fre- 
quently associated with chronic inflammation of the uterus. And 
I cannot but determine, as the result of my own observation, that 
they are secondary to the uterine inflammation in a large major- 
ity of cases, and caused by an extension of it. 

Cause of Cellulitis. — Dr. Bennett thinks increase of inflamma- 
tion of the uterine tissue, produced by strong cauterization, occa- 
sionally the immediate cause of cellulitis. Although this is doubt- 






COMPLICATIONS OF INFLAMMATION OF CERVIX. 187 

less true, yet a great many cases occur in which no local treat- 
ment has ever been resorted to. I do not remember to have met 
■with but one case in which this could have been the cause, and in 
that case it did not manifest itself until four weeks after the caus- 
tic potassa had been applied, for cervical induration and tumefac- 
tion. It is reasonable to suppose, however, that any circumstance 
which would excite the vessels as this does, might, and most likely 
would, enhance the probabilities of cellulitis. 

Rectitis as a Complication. — The rectum is very often diseased 
in uterine cases ; in fact, it is not often that inflammation of the 
uterus lasts for many months without affecting the rectum to a 
greater or less degree. Chronic inflammation of the rectum is 
quite a common complication with certain kinds of uterine diseases. 
The inflammation is evinced by the tenesmus, frequent discharges, 
and the increased secretion from the mucous surface. The symp- 
toms are those usually present when the rectum is inflamed from 
any other cause. The degree of inflammation will cause quite a 
difference in the intensity of the symptoms. In very many in- 
stances there is moderate tenesmus, causing five or six stools in 
the twenty-four hours. These are partly faecal, but thinner than 
natural, and loaded with mucus ; or there may be more tenesmus, 
with more frequent efforts at stool, less discharge, which consists 
mostly of mucus, streaked with blood. The discharges from the 
rectum in bad cases may be more or less purulent in character, or 
may consist exclusively of blood. 

Diagnosis of Rectitis. — Where there is rectitis, it is usually tol- 
erably high in this organ, being two, three, or four inches above 
the anus ; and in our examinations, if we press upon the rectum 
from the vagina, it is found to be quite tender to the touch, and 
always empty. It is too irritable to retain faeces for any length 
of time. So that when we find a mass of hardened faeces occupy- 
ing the rectum, very perceptible through the posterior wall of the 
vagina (and we will often find such), we may be pretty sure that 
the rectum is not much affected. 

Stricture of the Rectum. — Another condition of the rectum 
which is apt to be associated with rectitis in uterine disease, is 
stricture of this organ ; the stricture varying, of course, as to the 
time it has lasted and the severity of the cause. 

Fistula in Ano. — They may both be succeeded and accompanied 



188 COMPLICATIONS OF INFLAMMATION OF CERVIX. 

with fistula in ano. These complications have their own symptoms, 
and must be investigated and treated as though they were inde- 
pendent affections, while we attempt to remove the cause. 

Causes of the Rectal Diseases. — How these three different forms 
of rectal disease are produced by the disease of the uterus, al- 
though not very plain, may, I think, be generally explained. The 
inflammation doubtless extends from one tissue to another in rare 
instances; but more frequently, I think, it is caused by the pres- 
sure of the uterus upon the rectum. The rectum lies on the 
sacrum ; and the uterus often becomes so heavy that its supports 
are not sufficient to keep it in place ; it settles upon the rectum 
and presses it against the hard surface of the sacrum, thus irri- 
tating it very much, bringing about congestion and inflammation 
first, spasmodic and then organic stricture, and subsequently ulcera- 
tion and perforation of the mucous membrane of the rectum. The 
lumps of faeces or other substances burrow through the rectum, in 
this ulceration, when suppuration and exulceration establish a fis- 
tulous opening. 

Prolapse of the Rectum. — -But without much inflammation the 
rectum is sometimes prolapsed so that it protrudes from the body, 
either through the anus or the ostium vaginae. In long-standing 
cases of uterine disease, great relaxation of the mucous membrane 
of the rectum is a frequent occurrence; and then, in every effort 
at stool, it falls in large folds through the anus, often entangling 
the faeces in them, so the patient is under the necessity of picking 
them out before the evacuation can be completed. Or, what is less 
frequently the case, as the tenesmus of defecation attempts the 
expulsion of the contents of the rectum, this organ is forced for- 
ward into the vaginal cavity, and externally between the labia, so 
as to form a tumor external to them with the faeces contained in 
it. The evacuation of faeces from the rectum is very difficult in 
this complication, and the patient will tell us that she is obliged to 
introduce her fingers into the vagina, pressing the whole mass 
backward and downward toward the opening of the intestine. It 
is astonishing to what extent such displacements of the rectum are 
carried. Its folds often protrude sufficiently to cause a tumor 
below the anus or external to the vagina large as a man's fist. 

Hemorrhoids. — Hemorrhoids form another disease of the rec- 
tum and anus, which complicates diseases of the uterus. They of 



COMPLICATIONS OF INFLAMMATION OF CERVIX. 189 

course will not require a distinct description; their frequent occur- 
rence renders everybody familiar with them. The pain resulting 
from inflamed hemorrhoids often masks or simulates inflammation 
of the neck of the uterus ; and when they are associated, the cure 
of either will not remove the symptoms, so that we need not be 
surprised at their greater obstinacy when they coexist. The pro- 
lapse of the rectum and hemorrhoids are the unquestionable re- 
sults of uterine pressure. The continued congestion kept up in 
the rectal vessels by the constant pressure of the uterus upon the 
rectum, hypertrophies the mucous membrane, and causes varicosity, 
of the extremities of the veins, and in this way induces both re- 
sults. They are, therefore, the indirect results of inflammation of 
the uterus, this last bringing about a change in the position of the 
uterus, so that in some portions of it it presses the rectum against 
the sacrum so firmly as to embarrass its circulation and cause the 
changes above described. 

Hypertrophy of the Rectal Mucous Membrane. — The rectum is 
not only prolapsed, but the mucous membrane is hypertrophied 
quite largely, before it can appear externally; and in conjunction 
with this hypertrophy there is also great relaxation of the fibres 
of the rectum and sphincter ani, or of the fibres of the vaginal 
walls, to allow the escape of the parts to the enormous extent 
which sometimes takes place. 

Displacements of the Uterus. — The most common displacement 
of the uterus, where these two last rectal complications are pres- 
ent, is the subsidence of it in the axis of the superior strait. This 
brings the neck of the uterus straight down upon the rectum, and 
the whole weight of the uterus rests upon it. This brings me to 
the consideration of the most frequent of all complicating circum- 
stances connected with, chronic inflammation of the uterus, viz., 
uterine displacements. So frequent are these displacements in 
this relation, that, as I have before stated, they are regarded as 
the causes of all the associated difficulties. While I cannot assent 
to this view of the subject, I believe them to be frequently, if not 
almost invariably, the effects of inflammation, and am confident 
they are most important and mischievous complications, and prob- 
ably give rise to more suffering than any complicating condition 
whatever. As I have already stated, it is most frequently the dis- 
placements that cause stricture, hemorrhoids, and prolapse of the 



190 COMPLICATIONS OF INFLAMMATION OF CERVIX. 

rectum. By the uterus being crowded down upon the rectum, these 
affections may be produced. It will not be expected that I shall 
dwell with any great degree of minuteness upon the different de- 
grees or characters of displacements, or give a full description of 
them here, as I only wish now to speak of them as a complication 
of chronic inflammation of the uterus. 

Subsidence of the Uterus. — The most common displacement I 
meet with is a subsidence, or lapse, of the organ, while its vertical 
axis remains what it was before the change of position. This does 
not bring the uterus, or any part of it, nearer the vaginal orifice ; 
the lower end of it settles down upon the lower bone of the sacrum, 
while the fundus points upward toward the umbilicus. In exam- 
ining per vaginam, instead of finding the os uteri upon, or nearly 
upon, a level with the inferior border of the symphysis pubis, and 
touched by introducing the finger almost directly backward, it is 
necessary to bend the finger over the upper edge of the perineum, 
and carry it back and downward to the lower end of the sacrum. 
This displacement is very frequent, according to my observation, 
and does more injury by pressing upon the rectum, and gives more 
distress than almost any other displacement. It almost always 
obstructs the passage of the faeces through the rectum, and makes 
the patient feel as though the bowel was constricted at the point of 
pressure. After long continuance, it induces, in many instances, 
organic diseases of the rectum, inflammation attended by tenesmus, 
mucous and even bloody discharges, hemorrhoids, &c. All these 
rectal complications above mentioned may arise in this way. 

Anteversion. — The inflamed uterus is also anteverted, more or 
less, in many instances, so that the fundus presses heavily upon 
the bladder, while the os, higher up than in the first-named dis- 
placement, presses the rectum against the sacrum. But as most 
of the weight of the uterus is upon the bladder and anterior wall 
of the vagina, the rectum is not so distressed. 

Pressure upon the Bladder. — The greatest inconvenience is felt 
on account of its pressure upon the bladder. Frequent micturi- 
tion, sense of weight behind the pubis, &c, are its symptoms. 

Retroversion. — Retroversion is also not unfrequent as a trouble- 
some complication. As the fundus presses upon the lower part of 
the rectum and perineum, while the neck and os press upon the 
urethra and bladder, there is dysuria and rectal tenesmus of 



COMPLICATIONS OF INFLAMMATION OF CERVIX. 191 

greater or less intensity. The symptoms will be modified by the 
greater or less degree of malposition. 

Prolapse. — Common prolapse, with the mouth following the 
axis of the vagina, is the least frequent of these displacements, as 
I have observed them. It sometimes occurs, however, to a very 
great extent, and produces a great deal of distress. Compared 
with the other forms of displacement, it produces less inconveni- 
ence when present in the same degree. It certainly does not in- 
terrupt the function of the other pelvic viscera so much as sub- 
sidence, retroversion, or anteversion. Where excessive, it gives a 
sense of dragging and perineal tenesmus that are very disagree- 
able, but it does not cripple the patient, and render her unable to 
walk or stand, as is the case with the other displacements. "While 
displacements aggravate the sufferings connected with diseases of 
the uterus, they render the treatment more difficult, and often im- 
perfect, on account of the difficulty of exposing the os, and bring- 
ing the axis of the uterus to correspond with the direction of the 
speculum. 

Theory of Displacements. — I cannot now enter into the theory 
of displacements as complications of inflammation. I believe they 
are one of the effects of the pre-existing inflammation ; that they 
are brought about by the inflammation increasing the size and 
weight of the uterus, and thus causing it to settle down by virtue 
of its weight in spite of its supports ; that the suffering caused by 
the displacement results from its pressure on morbidly susceptible 
organs, made so, perhaps, by a long continuance of the pressure, 
and by the sense of soreness in the inflamed uterus itself, and also 
in part by traction upon the lateral and round ligaments. Still, I 
have no question that in very rare instances the displacement re- 
sults from other causes than inflammation, and then I can easily 
comprehend how it may produce inflammation in the uterus. The 
circulation must be embarrassed, congestions will readily occur 
on account of pressure and forcible flexion of the veins and arte- 
ries, and inflammation is very apt to follow long-continued conges- 
tion, &c. (See Displacements.) 



CHAPTER XV. 

POSITION OF INFLAMMATION. 

Submucous or Fibro- Cellular Inflammation. — Chronic inflam- 
mation may originally attack any portion of the uterus, from the 
fundus to the lower extremity of the neck, and be seated in either 
the fibro-cellular or mucous tissues. The part of the organ most 
likely to be attacked, however, is the cervix, and of this the mu- 
cous tissue is nearly always the seat of disease. When the inflam- 
mation originates or invades the fibro-cellular tissue of the ute- 
rus, it is soon followed by enlargement of the portion inflamed. 
If the posterior wall is thus affected, this is on account of an effu- 
sion of serum to some extent ; the part is thickened, and as more 
and more fibrinous coagulation takes place within the cellular tis- 
sue, it becomes hard as well as enlarged, and then we have a hard, 
tender tumefaction in that part of the uterus. When the sub- 
stance of the cervix is chronically inflamed, with or without co- 
existent mucous inflammation, it is enlarged, or, as Dr. Bennett 
has it, hypertrophied, at first not very hard, but if the inflamma- 
tion continues, there is hardness; hence we have hypertrophy, 
induration, and enlargement. Hypertrophy is not the word for 
this condition of things ; the part does not enlarge by an increase 
of existing tissue or a development of more of the same kind, but 
it is enlarged by an effusion of fibrine, which assumes an imperfect 
arrangement. It is increased in size in this way and also indu- 
rated. This kind of enlargement should be distinguished from the 
enlargement of congestion, — a condition in which the uterus is in- 
jected with an unusual quantity of blood, and its substance dis- 
tended by it. This is the case every month, but it becomes more 
permanent by the continuance of some point of irritation which 
keeps up an afflux of blood, and yet the irritation is so moderate 
as not to induce that stress of circulation necessary to an effusion 
in the tissues. We can, therefore, have chronic enlargement of 
the neck, and even the body of the uterus, without induration or 



POSITION OF INFLAMMATION. 193 

actual structural changes. This is often the case where the in- 
flammation is confined to the mucous membrane. Enlargement is 
no evidence, therefore, of fibro-cellular inflammation; induration 
must be superadded to make the whole of the changes necessary 
to constitute a case of it. When, therefore, we meet with an en- 
larged and indurated uterus, or cervix, we may with safety con- 
clude that it is suffering under chronic inflammation of the fibro- 
cellular tissue, with certain provisions that I shall have occasion 
to mention in future. When the uterus is hypertrophied, as in 
pregnancy, or in consequence of a growth or other substance which 
causes a development of tissue, the fibro-cellular structure is softer 
than natural. 

Hypertrophy. — The hypertrophy from growth is general, includ- 
ing the neck, body, and fundus ; the enlargement from conges- 
tion is not always, though most frequently, general ; the enlarge- 
ment accompanied with induration, and indicative of chronic in- 
flammation, is apt to be partial ; confined to the cervix, sometimes 
to one lip of the os uteri, or some part of the body near the neck. 
When the whole cervix is chronically inflamed, it enlarges in every 
direction ; the thickness is increased from the size of the end of a 
man's thumb to half the size of his fist, or even larger than this, 
and it is hard and tender to the touch. The cervical canal is de- 
creased in calibre in most instances, and somewhat lengthened. 
The induration is not always of the same intensity ; its hardness 
is often very great, at other times but little more than natural. 
As the induration and enlargement may be quite partial, the 
shape as well as size of the neck or portion of the body attacked, 
will seldom present its natural contour. The proportions of the 
different parts do not correspond in shape or size as they do in 
the healthy condition. Then we have in chronic inflammation of 
the differents parts of the uterus increase in size, hardness, and 
disproportion of corresponding parts, and hence alteration in shape, 
to which is almost always added tenderness upon pressure or touch, 
particularly with instruments. 

Hardness with Atrophy. — Although these statements will be 
found to correspond with facts so frequently as to constitute the 
rule with regard to the subject, yet there are important excep- 
tions. I have observed quite a number of instances, in which 
long-standing inflammation of the body of the uterus seemed to 

13 



194 POSITION OF INFLAMMATION. 

have brought about a shrunken condition of the organ. So that, 
notwithstanding the presence of all the symptoms, the uterus was 
very much diminished in size. It appears in such cases also to be 
indurated as well as decreased in its dimensions. It is barely pos- 
sible these uteri were congenitally smaller than usual, and what 
seemed to be atrophy was natural. In two instances I had assu- 
rance that in the early part of married life there had been preg- 
nancy and abortions. If this was true in these two cases, they 
must have been pathological. It has been supposed that the fibro- 
cellular form of uterine inflammation always precedes inflamma- 
tion of the mucous membrane for a greater or less length of time. 
This is certainly not always the case ; for we meet with inflamma- 
tion of the mucous membrane entirely unconnected with the sub- 
mucous tissue, as a simple affection. They are, however, much 
more frequently combined than separated from each other. 

Mucous Inflammation.— As a simple affection, that of inflam- 
mation of the mucous tissue is much the most frequent. Where 
they coexist, we have the increase of size, hardness, and irregu- 
larity of shape, indicating inflammation of the submucous sub- 
stance combined with the evidence of mucous disease. 

Seat of Mucous Inflammation. — The inflammation of the mu- 
cous membrane may extend to the whole of it, from the fundus 
through the cavities of the body and neck to the os, and then 
cover the whole of the vaginal portion of the uterus. This extent 
of inflammation is not very frequent, and when it occurs it almost 
immediately succeeds parturition or abortion, or is produced by 
gonorrhoeal inflammation. I have seen it under these circum- 
stances oftener than any other. It almost always causes a great 
deal of distress and suffering. 

Qavity of the Cervix. — Probably the most common extent of in- 
flammation is to the mucous membrane of the cavity of the cervix, 
and a portion or the whole of the membrane covering the intra- 
labial portion of the os. By far the greater number of instances 
that come under observation in practice are inflammation of the 
membrane around the os and inside the cavity of the cervix. I 
fear that this statement represents a fact that has not been gen- 
erally apprehended by practitioners. I am disposed to believe 
that too many practitioners have failed of success in curing their 
cases, because they have not followed up the inflammation suffi- 



POSITION OF INFLAMMATION. 195 

ciently above the os, in the cervix, being satisfied with curing that 
which was visible only, and, in consequence, leaving really the 
most important part of the affection untouched. 

Cavity of the Body of the Uterus. — Sometimes the inflammation 
is limited to the cavity of the body, to the cavity of the cervix, or 
to the membrane in and external to the os uteri. Inflammation 
limited to the cavity of the body of the uterus is not common, but 
I am quite sure that I have met with at least two instances. One 
of these had been treated for inflammation of the os and cervix, 
and cured of this, but the inflammation in the cavity of the body 
was left. The other had not had any treatment, as far as I could 
learn, for uterine disease. She had habitual leucorrhceal discharge 
of rusty-colored mucus, very much like the brickdust sputa of 
pneumonia ; the os externum was very small, and the os internum 
uteri large, as was also the cavity of the body. This patient did 
not menstruate, and had not for a number of years, and although 
married, did not become a mother ; the disease was caused by mis- 
carriage in early life. She was thirty-four years of age. 

Endocervicitis. — Endocervicitis alone, or inflammation limited 
or confined to the cavity of the cervix, is, on the other hand, an 
extremely common form of the disease. Not unfrequently this 
form of inflammation exists without any appearance of it in the os 
or external to it. When inflammation of the mucous membrane 
of the cavity of the cervix alone exists, it has certain effects upon 
the shape and other properties of the neck that are apt to attract 
our attention. Dr. Bennett describes the os as patent and the 
cavity of the neck enlarged, so as to admit the finger and permit 
the opening of it by a speculum to some extent, so that we may 
see the inside. Now, while this is very generally the case, it 
certainly is not always so. This condition of the os and cervix is 
more frequently met with near the menstrual periods than at any 
other time, and is probably always owing to the congestion of the 
vascular tissue of the cervix and about the os. 

Undocervicitis with Diminished Size. — I have undoubtedly seen 
many cases of this endocervicitis, in which neither the os nor cer- 
vical cavity were in the least enlarged, and others, in which the 
os uteri was contracted much below its natural size. The secre- 
tions of the mucous membrane are always modified ; generally 
they are very much increased, and often changed in character. 



196 POSITION OF INFLAMMATION. 

The j may become purulent or sanguineous, owing to the grade of 
the inflammation and the degree of congestion. The inflamma- 
tion situated external to the os on the end of the uterus, between 
the labia or their external surface, is very common, but it is not 
often limited to this part. It is almost always combined with 
endocervicitis. 

Certain forms of these mucous inflammations are found more 
frequently in certain sorts of patients. 

Endocervicitis in Virgins. — Virgin patients seldom have in- 
flammation external to the os uteri ; their disease is endocervicitis 
almost always ; very rarely there is a little rim of inflammation 
around the os upon the end of the uterus. 

Endocervicitis in Aged Women. — Again, in senile patients, 
women who have passed the climacteric period, and ceased to 
menstruate for some years, we find the inflammation in the cavity 
of the cervix. 

External Inflammation combined with Internal in Child-bear- 
ing Women. — In the married, child-bearing women, we find the 
external inflammation combined with the internal uterine inflam- 
mation of the mucous membrane. They are the kind of patients 
in whom most frequently the enlargements, indurations, and fibro- 
cellular inflammations are observed. The form of disease in per- 
sons who have been married, but never been pregnant, partake to 
some extent of the character of both the virgin and the child-bear- 
ing woman. They often have external, combined with internal, 
mucous inflammation, but not often fibro-cellular. Now, what I 
mean by these statements is, that these kinds of patients are likely 
to have the forms of disease which I have ascribed to them, but 
there certainly are exceptions to all of them. 



CHAPTER XVI. 

PKOGEESS AND TEKMISTATIONS, 

The intensity, terminations, and effects of inflammation upon 
the parts immediately implicated, of course will vary very greatly 
indeed. There can be no doubt that suppuration takes place in 
the fibro-cellular tissue of the uterus, especially the neck ; but 
that such an occurrence is very rare is also true. 

Progress in Submucous Tissue. — The inflammation of the sub- 
mucous tissue seldom proceeds any further in pathological changes 
than an effusion of fibrine, and its more or less complete solidifica- 
tion. When once arrived at this stage, it is likely to continue in- 
definitely, unless interrupted by some artificial or naturally inter- 
current circumstance. The tendency of inflammation of this tissue 
is not to stop short of fibrinous effusion, and remain stationary for 
any length of time ; it is either resolved before or soon attains to 
it. Whether inflammation commences in the deeper tissues, and 
affects the mucous membrane secondarily, is a subject which can- 
not be very often demonstrated. The probability is that this is 
occasionally the case ; but what occurs more frequently, I think, 
is the transition of the inflammation from the mucous membrane 
to the submucous tissue, particularly in the neck and about the os. 
Hence it will be found that a case, as I have verified more than 
once, which this year presents only a tolerably bad form of mu- 
cous inflammation, without any tumefaction or hardness of the 
neck, in twelve months will present the tumefaction and indura- 
tion characteristic of fibro-cellular inflammation. 

Intensity of Mucous Inflammation. — In the mucous membrane 
the inflammation continues for an uncertain length of time with- 
out complicating the other tissues, and there is a very great dif- 
ference in its intensity and effects. We often meet with inflam- 
mation of the mucous membrane of sufficiently mild grade to 
merely cause a slight increase in the color, heat, and secretion, 
without producing tissual changes. One thing which ought to be 



198 PROGRESS AND TERMINATIONS. 

remembered, and I shall not apologize for the reiteration, is, that 
a permanent increase of secretion in a mucous membrane is, and 
should always be, regarded as an evidence of inflammation in it. 
Another not less important fact is that discolored mucus, either 
yellow, red. or otherwise, is not produced by a mucous membrane 
which retains its tissual integrity. Blood cannot get through 
the capillaries of a sound membrane, and pus is not produced by 
a mucous membrane while the epithelium retains its perfect in- 
tegrity. 

Progress of Mucous Inflammation. — After the inflammation has 
lasted for a time, if its intensity is increasing, the epithelium gives 
way more or less completely. The destruction or rather the want 
of reproduction of epithelial scales, is generally observed in patches. 
At the point where the inflammation attains to the greatest inten- 
sity, the epithelium is not maintained. However small this point 
may be, the redness is increased ; and if we look at it we see that 
the place is scarlet-colored instead of a pale rose-color, as when 
the epithelium is entire. Inasmuch as this is loss of substance, 
although slight, it is ulceration, or abrasion, the beginning of ul- 
ceration ; as yet the secretion is merely increased in quantity, or 
at most very slightly discolored with pus-globules, and rendered a 
little thinner by the exudation of a small amount of serum. This 
absence of epithelium is generally observed, where it occurs, in one 
continuous patch of greater or less dimensions, and indicates a not 
very intense degree of inflammation. When this effect of inflam- 
mation is first observed, it is apt to be situated around the os uteri ; 
but I have occasionally seen it over the whole intra-vaginal portion 
of the neck. The cases in which I have observed this state of ex- 
tensive abrasion were in persons w T ho had passed the climacteric 
period of life, and they were the subjects of copious, watery, very 
irritating, and slightly yellow leucorrhoea ; and upon examining 
them I was forcibly reminded of the chafed condition of the thighs 
in fleshy persons, so red and fiery was the appearance presented 
by it. They were obstinate, and it required great care in the use 
of remedies not to aggravate the inflammation. 

Forms of Ulceration. — This epithelial denudation is the simplest 
and the most common form of ulceration met with in practice. 
Of course, in this form of ulceration the red portion is not de- 
pressed ; it retains its level with the adjoining surface, and conse- 



PROGRESS AND TERMINATIONS. 199 

quentlj the term ulceration is not considered applicable to it by 
those who do not believe in uterine ulceration at all. After this 
description, as faithful a one as I can give, the reader will form his 
own judgment. I hope I may be allowed to consider it a breach 
of continuity of the mucous membrane, while anatomists persist 
in describing the epithelium as a part of that membrane. After 
the epithelium is lost for some time, there is a gradual increase in 
the size of the papillary structure of the membrane covering the 
neck of the uterus ; and if the membrane is now examined, instead 
of the smooth redness there is something of a velvety or plushy 
appearance. The intensely red surface is covered by, or rather 
seems to be formed of, an infinite number of extremely minute 
projections, so closely apposed, that there is hardly any space be- 
tween them. Scarlet velvet is a very good representation of its 
appearance. The papillary projections do not seem larger than 
the minute silk fibres of velvet, as short and as thickly set. This 
surface is almost always covered with mucus and pus in different 
proportions of admixture. There is always pus, however, when 
this complete absence of the epithelium is observed. Still, the 
evenness of the mucous surface is not disturbed. There is no ex- 
cavation at least. If there is any change in this respect, the red 
patch is very slightly elevated above the surrounding surface. As 
the inflammation advances, the papillary development is greater, 
but also somewhat different ; some of the papillae increase faster 
than others, crowd upon the smaller ones, cause them to disappear, 
and usurp the space occupied by their oppressed neighbors. If 
the membrane is now examined, there will be seen, instead of the 
numberless minute, closely set papillae, a greater or less number of 
larger ones, varying from the size of a small sewing-needle to a 
large pin's head, thickly studding the red surface. The redness 
now, as a general thing, is not so intensely scarlet. The ends of 
these papillae, which rise from half a line to a whole line above the 
level of the surface upon which they stand, are darker red, inclin- 
ing to lividity. The papillae thus increase in size, and decrease in 
number, by strangling each other, until some of them attain the 
size of small shot, and look like warts. The larger they are, the 
greater is their lividity of color. As will be inferred, the diseased 
surface is more and more elevated and irregular, until very con- 
siderably raised above the surrounding level. In such cases, pus 



200 PROGRESS AND TERMINATIONS. 

is generally poured out, in considerable quantities, from the spaces 
between the papillae, and the whole surface is thickly covered with 
tenacious mucus, colored with pus, or with nothing but pus. Some- 
times, however, such surface produces no pus or mucus, and seems 
preternaturally dry. 

Complication of Mucous with Submucous Inflammation. — This 
sort of mucous inflammation is seldom observed without being ac- 
companied by submucous inflammation as a complication. There 
is nearly always considerable enlargement and induration of the 
whole cervix where these greatly enlarged papillae present them- 
selves. In such cases as these, I think we may safely conclude 
that the inflammation commenced in the mucous membrane, and 
passed from it to the deeper structures. But there is another kind 
of enlarged, hardened neck, which with equal certainty begins in 
the fibro-cellular tissue, viz., when in connection with great hard- 
ness and enlargement, the surface deprived of its epithelium is ex- 
tensive, and is uneven, or nodulations of moderate elevation, but 
greater extent of superficies than the papillae, exist, reminding one 
of the rough surface of very coarse sacking or sea-grass carpeting. 

Ulceration and Enlargement. — This kind of a surface is always 
seen upon a greatly enlarged cervix, which also is very much in- 
durated. It is a very obstinate and very discouraging state of the 
disease, but will usually yield to sufficiently energetic and long- 
continued treatment. The boldness in the use of caustics neces- 
sary to the cure of such cases as these, requires strong nerves to 
institute and thoroughly execute. In the varieties I have here 
noticed, the surface is more or less elevated. But instead of papil- 
lary development after the destruction of the epithelium, the in- 
tegrity of the mucous membrane is further invaded ; the surface 
becomes somewhat depressed, with the edge of the red portion 
well defined ; in short, ulceration, as it is usually understood, be- 
comes quite evident. I should have stated before that in many 
cases, where the epithelium only is destroyed, the red patch shades 
off into the healthy rose-color imperceptibly. In this last kind of 
ulceration the termination of the two is more abrupt. 

Aphthous Inflammation. — Other sorts of ulceration occur less 
frequently on the neck of the uterus, — isolated, small ulcerations, 
several of them set upon a red surface, not unlike what we see 
upon the lips and inside of the cheek ; also there are occasionally 



PROGRESS AND TERMINATIONS. 201 

aphthous, or curdy spots, elevated somewhat, but soon degenerat- 
ing into little yellow ulcers. I have, on one or two occasions, seen 
such ulcers in patients who w r ere the subjects of nursing sore 
mouth, and I always regard these minute isolated ulcers as the 
effect of constitutional disease ; or they at least receive their pecu- 
liarity from the condition of the system, and indicate a general 
unhealthy state of the mucous membrane. It would hardly be 
proper for me to stop here to describe all the particular sorts of 
ulceration that occur ; in addition to those resulting from inflam- 
mation, there are some which are the effect of specific diseases. 
These specific ulcers do not assume any peculiarity, nor are they 
particularly modified by their location upon the neck of the uterus. 
A chancre possesses its characteristic, when planted upon the neck 
of the uterus, as distinctly as when seated upon the glans penis. 
There is no difference between the peculiar, ragged, insensible, 
foul ulcer of scirrhus on the neck of the uterus and the mammary 
gland. The phagedenic ulcer of the uterus is the same as when 
observed to dissolve down so rapidly the tissues of organs else- 
where, and it would not be proper for me to draw their diagnostic 
characters here. A very little experience, care, and reflection, 
will save anybody from error of diagnosis or treatment, when the 
question of difference between common ulcer of inflammation and 
specific ulcer presents itself. 



CHAPTER XVII. 

DIAGNOSIS. 

Fortunately for suffering woman, we may arrive at demon- 
strative knowledge of the extent, nature, and locality of diseases 
of the uterus; and, as a consequence, treat her diseases with the 
certainty which a positive diagnosis always insures. The evident 
advantages of a physical diagnosis will render it quite unneces- 
sary for me to use any argument in favor of it, or to induce med- 
ical men to resort to it. A physical examination, however, of the 
genital apparatus of females, is quite a different matter from a 
physical examination of the chest, eye, ear, or any other organ 
of the body ; and hence the necessity of approaching and conduct- 
ing it under conditions rendered imperative on account of the cir- 
cumstances connected with it. The education and natural sense 
of modesty, so appropriate to female character, and which always 
command the respect of gentlemen, make such examinations dis- 
gusting and disagreeable above almost all others demanded by 
the necessities of woman's circumstances. With a view to this 
fact, it is our duty, by our conduct toward our patient, and the 
management of the examination, to divest it as nearly as possible 
of every disagreeable feature. Medical men generally I think 
are, as they should be, actuated by the above considerations, and 
I fear that they are often so influenced by their own sense of del- 
icacy as too frequently to abstain from the enforcement of essen- 
tial investigations. This is an error we should always bear in 
mind, and I think we shall less frequently regret a thorough, al- 
though somewhat indelicate examination, when dictated by an 
honest and intelligent conviction of its necessity, than regret a 
neglect of such examination from too great a deference to the 
mere shame of our patients. We should not be, in important 
cases, constrained to take things for granted that we are not sure 
exist. Our bearing to a female patient should be deferential, can- 



DIAGNOSIS. 203 

did, and modest. She should be convinced by our demeanor that 
everything we do and say is strictly necessary and relevant to 
her case, and has its foundation in our solicitude for her welfare 
alone. Nothing therefore should be said or done but what is 
called for and obviously proper. This sort of treatment from her 
medical adviser will always command the confidence and earnest 
co-operation of an intelligent female patient. There should be 
a full and explicit understanding between the physician and the 
patient as to the necessity of a physical examination, in what it 
consists, and how it is to be conducted. The good sense of the 
practitioner will enable him to judge whether he should commit 
the detail of explanation to the husband or some other appropri- 
ate second party, or whether he impart it directly to the patient ; 
all the circumstances of the case will enable him to determine this 
matter without much difficulty. After the preliminaries are dis- 
posed of, I would insist upon conducting the examination without 
exposure. It is needless in ordinary uterine examinations, and 
should be permitted only when the disease is upon the external 
parts. One position and kind of preparation, so far as the patient 
is concerned, will suffice for most cases, whether we wish to make 
a manual or instrumental examination. There is no necessity for 
the patient to unclothe herself. 

Position of Patient. — She should lie down on her back across 
a bed, so that the breech will be very near the edge : draw up her 
limbs by flexing the thighs and knees, and place her feet, sepa- 
rated about twelve inches, upon the side .of the bed very near the 
nates. In this position a sheet should be thrown over her, so as 
to completely cover her person, and hang down several inches 
below her feet, over the edge of the bed. If we wish to use the 
speculum, or our eyes in any way, the bed should be placed imme- 
diately before a large window, in which the light is net obstructed 
by blinds or curtains. Thus placed, by kneeling down before her, 
we can have free use of both hands, a matter of much importance 
in delicate manipulations. Let the patient be very near the edge 
of the bed, lest by reaching too far, our examinations may be dif- 
ficult, if not imperfect. When we wish to make a manual exami- 
nation, we have need of nothing further than a little oil. Our 
objects in making a manual or digital examination are to ascer- 
tain the position, size, consistence, and sensitiveness of all the 



204 DIAGNOSIS. 

organs in the pelvis;' the presence or absence of anything that 
does not belong there ; and if anything unusual is there, what are 
its properties, connections, and nature. Upon making examina- 
tions for the first time, the whole of this investigation should al- 
ways be attended to. 

Digital Examination. — The mode of examining the pelvis with 
the fingers is of the utmost importance. After oiling the fore and 
middle fingers the index should be very gently introduced, and 
the examination conducted as far as possible with it ; then the two 
should be introduced, with which nearly all the cavity of the pelvis 
can be reached. The index finger will not reach as far, by one 
and a half to two inches, as the two together. As the finger is in- 
troduced, it naturally and easily comes in contact with the rectum, 
which may contain faeces, and consequently will appear as a round, 
full ridge along the middle line of the posterior wall of the pelvis, 
or a mere soft fibrous cord, hardly perceptible to the touch. The 
full rectum is generally a healthy one, as the faeces cannot remain 
long in a rectum rendered irritable by disease. By pressing upon 
the rectum with the finger, we may ascertain the presence of in- 
flammation by the increased sensitiveness ; the organ is absolutely 
insensible to moderate pressure when in a state of health. We 
should seek for internal hemorrhoids, which are small tumors in 
the bowels, or the induration and contraction indicative of stric- 
ture ; and, in short, examine it as completely as possible in this 
way. Next we should turn our finger forward, pass it up behind 
the symphysis pubis, and along the front wall of the vagina, and 
as well as practicable ascertain the condition of the bladder. It 
may contain a calculus or other foreign substance, or, what is very 
much more common, be inflamed. In the first case, the foreign 
body may be felt by the finger. The examination is more com- 
plete if the fingers of the left hand are used to press into the pelvis 
from just above the symphysis pubis. The substance can thus be 
grasped by the fingers of the opposing hand. With the fingers of 
one hand above the bladder, and the other in the vagina below it, 
we press it and thus ascertain its sensitiveness. With the two 
fingers of the right hand pressing up by the side of the uterus, 
between it and the walls of the sides of the pelvis, first on one 
side and then the other, while the fingers of the left hand press 
downward toward them from above, so as nearly as possible to 



DIAGNOSIS. 205 

meet them, the cavity may be pretty thoroughly explored, and any 
unnatural substance or uncommonly sensitive tissue be easily dis- 
covered. All these manipulations should be performed with the 
utmost gentleness, remembering that rudeness may deceive us as 
to the sensitiveness of organs, as well as give the patient unneces- 
sary suffering. While we are gentle, we should be as thorough as 
possible. The main object, however, for which we institute these 
examinations, is to ascertain the condition of the uterus with re- 
spect to position, size, shape, consistence, sensitiveness, &c, &c. 
Where is or ought to be the os uteri and cervix, and how shall 
we find them ? In the virgin, the os uteri ought to be in the 
middle of the pelvis, upon or a little below the level of the arch 
of the symphysis pubis, and within easy reach of the index finger, 
two inches and a half from the entrance of the vagina. We may 
know when we feel the neck of the uterus by its consistence, shape, 
size, &c. It has more consistence than any part with which our 
finger comes in contact, as we push it backward into the vagina. 
In passing through the vaginal canal, the finger is impressed with 
a soft intestinal sensation, and can distinguish nothing but loose 
folds that are dissipated and lost in the surrounding softness by 
the slight pressure, until it comes to the neck of the uterus, when 
it may be felt, having consistence enough to retain its shape under 
considerable pressure. If we push it upward, backward, or down- 
ward, it retains the same characteristics. The finger can be 
carried up the side, up before, or behind it as a projection, and 
around it in every direction except above. This being unlike 
anything else in the vagina, will be easily recognized by an un- 
educated finger. The shape of the virgin cervix uteri is almost 
cylindrical, slightly compressed from before backward, and not far 
from three-quarters of an inch in diameter in every direction ; it 
projects half an inch into the vagina, and the projecting or free 
end of it is apparently cut nearly square off, so as to present at 
its inferior face almost a flat surface, with a mere dimple in the 
centre corresponding with the os uteri. The multipara cervix 
uteri is generally a little lower in the pelvis, and often slightly 
turned to one side, does not project so much into the vagina, is 
about an inch wide, or often a little more, from half an inch to 
three-quarters in its anterior posterior diameter, and instead of 
being truncated, seems formed of two distinct projections at its 



206 DIAGNOSIS. 

inferior extremity (the anterior and posterior labia of the os uteri). 
Between the labia or projections is a deep fissure, with its extremi- 
ties directed to the sides, large enough to partially admit the ex- 
tremity of the index finger. Os tincae is applicable to this form 
of the os uteri, but in no wise is expressive as connected with the 
shape of the virgin os uteri, neither is it descriptive of the senile 
uterine mouth. 

Os Uteri in the Aged. — The os uteri in the old is higher in the 
pelvis than in the virgin or multipara, does not project into the 
vagina, and feels more like a pit at the termination of the vagina. 
As women advance in age this description is more applicable than 
very soon after the cessation of the menstrual discharge. There 
is often a cord or frsenum-like projection in the vaginal walls, 
which is planted into the external surface of the anterior and 
posterior lips of the mouth of the uterus, and thus extends back- 
ward and forward to be lost in the anterior and posterior median 
line of the walls of the vagina. This frgenum is more apparent, if 
not more developed, as women advance in age ; but I have known 
it so prominent as to be mistaken for the results of disease, even 
in the middle-aged. In one case an intelligent practitioner thought 
it an evidence of the injurious effect of strong caustics. The con- 
sistence of the virgin and multipara cervix uteri is the same. To 
the sense of touch it gives the idea (which is a correct one) of deep 
fibrous tissue, almost as hard as cartilage covered over thickly 
with areolar tissue. Dr. Bennett compares it to the feel of the 
cartilage of the lower extremity of the nose. It seems to me not 
quite so dense, although nearly so. It is wholly insensible to 
pressure with the pulp of the finger, and it requires considerable 
force to produce pain with a plain round instrument. This fact 
should be borne in mind in our examinations, viz., a healthy cer- 
vix uteri is not tender to the touch. 

Corpus Uteri.— We may examine the shape, size, and sensitive- 
ness of the body of the uterus by pressing it down well into the 
pelvis with the left hand, while the fore and middle finger of the 
right presses upon it as high up as possible. When the uterus is 
healthy, the fundus cannot be felt above the symphysis, even by 
lifting it with our fingers, so that if it can be felt by both hands 
it may be considered enlarged. 

A Tender Uterus is an Inflamed Uterus. — I cannot refrain from 



DIAGNOSIS. . 207 

emphasizing the fact that the uterus is insensible to the handling 
of an ordinary examination, and that a tender uterus is a diseased 
uterus; in fact, generally inflamed. What condition converts 
comparatively insensible organs elsewhere — the periosteum and 
cartilages, for instance — into highly sensitive ones ? 

Examination of Urethral Canal. — If we have gained all the in- 
formation we can from the use of the fingers, we may next use the 
probe, for the purpose of penetrating the cervical and uterine 
cavities. When, from the sense of touch, there is suspicion of 
inflammation of the urethra, the probe may be used with great 
propriety in examining this canal. There is almost always pain 
when the probe is introduced into the healthy urethra, but it is a 
peculiar smarting pain ; if the urethra is inflamed it is a sore pain ; 
it feels as though the probe had touched a sore place ; it is sore- 
ness. Dr. Simpson first recommended and practised the use of 
the probe for the purpose of probing the uterus, and he has given 
to it a certain appropriate shape, size, and adjustment, which add 
very considerably to its usefulness and adaptability to this par- 
ticular use. It may be found in almost any of the shops of our 
instrument makers, under the name of Simpson's uterine sound. 

Object in Using Probe. — The main objects in examinations with 
the probe in such cases as I have now under consideration are, to 
measure the size and length of the cervical and uterine cavities, 
the mobility and position of the uterus, and, if need be, the con- 
nection of that organ with pelvic growths. The instrument must 
be adapted to these purposes ; in order to this it must be long 
enough, of the right size, and made of flexible metal. 

Size and Length of Probe. — It should be ten or twelve inches 
long, with one end fixed to a flat handle ; the probe end should 
be terminated with the ordinary probe-pointed enlargement, about 
one-eighth of an inch in diameter. The wire behind the bulbous 
termination should be one line in diameter, round and smooth, and 
should gradually increase in size to the handle, where it ought to 
be about a quarter of an inch in diameter. The best material, I 
think, is copper, galvanized. I have not spoken of notches and 
other scale-marks upon it, because I like it better plain. Yet I 
see no objection to them as recommended by Dr. Simpson. It is 
always well to have two or three sizes of probes for special pur- 
poses, but the one I have here described is the one I should rec- 



208 



DIAGNOSIS. 



Fig. 16. 



ommend, to arrive at any deviation from the natural uterine 
measurement. 

Mode of Using. — After oiling the instrument, and 
introducing the index finger of the right hand, and 
placing it upon the os uteri, the probe may be carried 
along the palmar surface of the finger until the point 
arrives at the mouth of the uterus, when by elevating 
the point, it may be carried forward into the cavity of 
the cervix. In order to insure its passage through the 
cavity of the cervix into the cavity of the body, the 
probe must be bent to the same degree of curvature as 
a male catheter. Great gentleness must be observed 
in the use of this instrument, because it is an easy 
matter to do violence to the mucous membrane by a 
very little rudeness of management. After the probe 
has passed to the os internum, a sense of constriction 
is felt through the instrument, which feeling soon gives 
way, and the probe then goes to the fundus without 
further resistance. 

Length of the Cervical and Uterine Cavities. — The 
cervical cavity in the virgin is about an inch and a 
quarter in depth, and the cavity of the body from a 
half to three-quarters of an inch; the former in the 
multipara is one and a half inches, and the latter an 
inch deep. In old age they both are nearly or wholly 
obliterated. I do not often use the probe in this way for 
the examination of the uterus in cases of inflammation 
and ulceration, but have adopted the suggestion of 
Prof. Miller, of Louisville, and use it through the spec- 
ulum, and shall consequently have more to say about 
it in connection with the use of that instrument. To 
expose the neck of the uterus so as to examine it by the sense of 
sight, it is necessary to have a speculum, and we ought to have a 
pair of long light dressing forceps also ; they will be very useful 
on several accounts. 

Speculum. — Since the speculum has come into so general use, it 
has assumed a variety of shapes, and been composed of quite a 
number of different sorts of materials. For different purposes it 
is convenient, if not necessary, to be provided with different shapes, 



Uterine Probe 
or Sound. 



DIAGNOSIS. 



209 



Fig. 17. 



sizes, &c, of this instrument, but for ordinary use, the common 
cylindrical, or quadrivalve, are the best forms. My preference is 
for the compound called " German silver." If we use the cylin- 
der, we ought to have three different sizes : one small, one large, 
and the other a medium size. With regard to the adaptation of 
the cylindrical instrument, the larger size we can use in the case 
the better, as it will the more completely expose the cervix. In 
selecting the cylindrical-shaped instrument, we should procure one 
with as great bevel at the internal end as we can find. There 
should also be always adapted to 
it a wooden director. The instru- 
ment will pass the external parts 
with less pain, and will not require 
the care to prevent it from injur- 
ing the vagina, that it will without 
the director. 

The common glass instruments, 
whether plain or covered, as re- 
commended by Fergusson, I never 
use, excepting for the purpose of 
leeching. The instrument I pre- 
fer above all others for ordinary 
use, is the quadrivalve made ac- 
cording to Charriere's plan, or 
what is equally as good, perhaps, 
Tieman's new quadrivalve. The 
former has a plug, or director ; 
the latter is so arranged at the 
ends of the blades that they close 
in together, and make the internal 
end of the instrument smaller, and 
render the director unnecessary. 
One quadrivalve will answer al- 
most any case that occurs, if it be 

of medium size. It is constructed of four blades, that are caused 
to open or close by the use of a nut upon a screw. After intro- 
ducing the instrument, the internal end may be increased greatly 
in size, without the external end being enlarged at all. It is only 

14 




Quadrivalve Speculum. 



210 DIAGNOSIS. 

necessary to see it to perfectly understand its construction and 
the mode of managing it. A good instrument of this sort may 
be procured at Messrs. Tolle & Dagenhardt, or Messrs. Bliss & 
Sharp, of Chicago. 

Position of Patient for Speculum — To be prepared to use this 
instrument to the best advantage, our patient should be placed in 
the position I have heretofore described, viz., across the bed, be- 
fore a large window, through which as much daylight should be 
freely admitted as possible. The better light the better view, and 
unless we have plenty, we cannot be certain of correct results in 
our examinations. The bed and patient should be so placed that 
the light may fall straight through the instrument, and full upon 
the parts at its internal extremity. We should also have some 
cotton-wool, sweet oil, and a couple of napkins, together with the 
dressing forceps I have before spoken of. 

Mode of Using the Speculum. — In commencing the examination, 
we should oil our speculum, and our middle and index fingers. 
Kneeling before the patient, we should introduce the index finger, 
and, if need be, the middle one also, to ascertain the position of 
the cervix uteri. This precaution will enable us to know in what 
direction, and how far, to introduce the speculum. After this pre- 
liminary examination, the forefinger and thumb of the left hand 
should be placed upon the edge of the labia, one upon each side, 
with which they should be gently separated; holding the speculum 
in the right hand, somewhat like a pen, we may introduce it by 
the guidance of the thumb and finger placed as above. In intro- 
ducing it, we should push it forward sufficiently to reach the cer- 
vix, and direct it upward, downward, or to one side, as we may 
have ascertained, by digital examination, to be the position of the 
os and cervix. The director may now be removed, when the os 
uteri will be seen at the open end of the tube. 

How to Find the Os Uteri. — If this is not the case, we may use 
our probe, and gently push the parts from one side to the other, 
turning the speculum in different directions, until it is found. If 
the neck is too large to enter the speculum, we may spread the 
blades still more, until it is brought into full view. Most fre- 
quently the parts are covered with some sort of secretion, and 
we should always, with cotton-wool or lint, remove all of it, so that 
the naked mucous membrane alone presents itself to our view. 



DIAGNOSIS. 211 

Without this precaution, we may overlook an obvious and exten- 
sive ulceration ; for as the parts are covered over with this thick, 
opaque secretion, it either completely hides them from view, or 
much modifies their appearance. I have often met with cases 
where I have observed them attentively, for the purpose, if pos- 
sible, of detecting ulcerations without this step, but failed, until 
the cotton was used, when extensive ulceration appeared. Indeed, 
I never think of coming to a conclusion of any kind by the use of 
the speculum, without this precautionary measure. By means of 
the sight, we can see the color, size, shape, and some other condi- 
tions of the parts, and the color, consistence, and derivation of the 
secretions. When the mucus, pus, or blood comes from the mouth 
of the uterus, we can see it issuing from it. The shape and size 
of the neck and os of the uterus differ in different individuals, ac- 
cording as they have been impregnated or not. 

Appearance of the Os and Cervix in the Virgin. — The virgin 
uterus is small ; the cervical end is nearly round, and terminates 
in a truncated extremity. Through the speculum, it does not pre- 
sent the appearance of labial projections, and the os is either a 
small slit about a quarter of an inch long, or a round opening into 
the middle of the truncated extremity. It is about large enough 
to admit with facility the end of a female catheter, and the neck 
projects, in relief, from the bottom of the parts exposed by the 
speculum, something like half an inch. 

Appearance in the Muciparous Uterus. — The appearance of the 
muciparous uterus is quite different from this ; the cervix termi- 
nates in labial projections, which divide its extremities into an an- 
terior and posterior half, and it does not project with so much prom- 
inence into the speculum. The os is represented by the cleft 
between these labial projections, and is large enough, in many in- 
stances, to admit the tip of the index finger. 

Appearance in the Aged. — In the aged, the labial projections 
seem to have atrophied to obliteration, and the speculum shows a 
round opening, surrounded by the walls of the vagina. 

Exceptions to these Appearances. — Although the above is an ac- 
curate description of these appearances under the different circum- 
stances, there are many natural deviations from it. 

Color, — The color of the mucous membrane covering the cervix, 



212 DIAGNOSIS. 

and entering the os uterus, may be compared to that of the inside 
of the lips of the mouth, a pale rose red. 

Appearance of Secretion. — The parts are merely lubricated, not 
smeared or inundated, with mucus. There is just enough of this 
secretion to keep the membrane moist, but not enough to hide the 
surface from view. I speak now of the cervix uteri. 

Indication of Mucus in Abundance. — An abundance of mucus 
must be regarded as an evidence of excitement ; its constant and 
persistent abundance as an evidence of disease. " Remember that 
in spite of their name, it is not the business of mucous membranes 
to secrete mucus ; the more perfect their condition, the more favor- 
able the surrounding circumstances, the less they do so 

The greater the diminution of their life, the greater the secre- 
tion." The more disease, the greater the secretion, until their in- 
tegrity is destroyed, when the secretion becomes modified. The 
source whence the mucus is derived will show the point of disease ; 
if it comes from the os uteri, the disease is in the cavity of the 
cervix, or body of the uterus. 

Indication from Pus. — These remarks apply with greater force 
to the production of pus by the vagina or cervix. Pus, or puru- 
lent mucus, indicates disease ; and when we find muco-pus, or 
clear pus, in the end of the speculum, it would be preposterous to 
conclude that there was no disease there, merely weakness of the 
parts. It is extremely doubtful whether pus can be produced by 
mucous membrane, without destruction of the epithelium, at least. 
Temporary congestion often increases the amount of mucus to be 
found in the vagina, but no pus. The coloi; of the mucous mem- 
brane, in cases of congestion, is a livid or a dark purple red, in- 
stead of the scarlet or abrasive inflammation. 

Probe and Speculum Conjointly. — When the neck of the uterus 
is exposed in the speculum, it will often be profitable to use the 
probe. If proper attention is paid to appearances under the use 
of the probe, much information may be gained. When the mu- 
cous membrane of the cavity of the cervix or body is inflamed, it is 
generally much more fragile than natural, so that it bleeds upon 
slight contact with the end of the probe. In cases where the in- 
flammation extends to the cavity of the uterus, the probe passes 
the os internum without obstruction, and passes farther up than 
natural from the increased size of the cavity. 



DIAGNOSIS. 213 

Characteristic Signs of Inflammation. — The signs of inflamma- 
tion of the submucous tissue or substance of the neck of the ute- 
rus are, increase of size, tenderness, and generally hardness ; of 
the mucous membrane, increased color and secretion ; of ulcera- 
tion, still more intense redness, purulent discharge, tenderness, 
and generally enlargement. The former conditions may be as- 
certained by the touch, the latter by the sight, and when they are 
mingled, by both combined. It may be superfluous to pursue the 
diagnostic description of these cases further ; but as I believe that 
a great many members of the profession do not sufficiently appre- 
ciate the importance of some of the appearances and conditions I 
have described, and as I am thoroughly convinced of their signifi- 
cance, I am determined, at the risk of reiteration, to place these 
diseased appearances and conditions in a more prominent light. 
Open external ulceration of the uterine cervix, after the parts. 
are well exposed, and cleared of mucus and pus, by wiping, can- 
not be well mistaken, or overlooked ; and the only thing I shall 
insist upon here is that the practitioner must not be led to believe 
the case one of no importance because the ulceration is not very 
extensive. This raw scarlet surface is always indicative of mis- 
chief; and we should expect any amount of suffering from even 
small patches of it. There are cases where the appearances are 
not so obvious ; where in fact all the parts exposed by the specu- 
lum and within reach of our vision have a natural appearance. 
No redness, rawness, or other discoloration can be detected on the 
neck, in the mouth of the uterus, nor on the vaginal surfaces ; they 
are quite healthy in appearance and reality. 

Diagnosis of Endocervieitis. — But there is an obvious and in 
many instances a copious secretion of tenacious mucus flowing 
from and lying in the os uteri ; wipe this away and all looks right. 
This is a case of endocervieitis. In some instances this mucus is 
colored with streaks of yellow by the presence of pus, or it is 
w T holly yellow ; here there is loss of integrity in the epithelium of 
the cervical cavity. The mucous membrane in the cervical cavity 
is ulcerated. If we remember that the mucous membrane secretes 
only enough mucus for lubricating purposes, in the natural condi- 
tion, we can arrive at no other conclusion than that the mem- 
brane is in a state of hyper-excitement when its secretion is 
rather abundant, or altered, or both. When we see mucus in even 



214 DIAGNOSIS, 

small, yet perceptible quantities, issuing from the anus, what is 
the inference ? If this is abundant, persistent, and colored yellow, 
however healthy the anus might appear externally, we could not 
believe that the rectum was in a healthy condition. Why not then 
positively determine that the mucous membrane is inflamed, which 
floods the os uteri with mucus or pus, or with both ? If we intro- 
duce the probe into the cavity of the cervix thus abundantly se- 
creting, the patient will nearly always complain that we touch a 
"sore place; a tender spot;" that it hurts her in her back, &c. 
&c. And very often blood will immediately follow the withdrawal 
of the instrument. This, however, is not invariably the case. 
Another diagnostic evidence of endocervicitis, is the increase of 
the pain ordinarily experienced by the patient when the probe or 
nitrate of silver is introduced. 

Diagnostic Effect of Caustic Applications. — There is not a new 
pain produced, but the old pain is aggravated, and the quality of 
the symptoms is the same while the number is increased. If the 
pain in the sacrum has been the one mostly complained of, the in- 
troduction of the caustic makes the back ache worse ; if the pain 
in the iliac region has caused most suffering, it will be aggravated. 
The hyper-secretion, or perverted secretion of the mucous mem- 
brane, must be regarded as an indication of disease of that mem- 
brane. If we have these facts fixed in our mind, and if we act 
upon them, we may discover and cure disease that would otherwise 
escape our attention and thwart our skill. But there is another 
obvious and common sense sign of inflammation, which has not 
been applied in our investigations of diseases of the uterus, viz., 
tenderness. Tenderness or sensitiveness to the touch anywhere 
else, leads us to suspect inflammation, but in the uterus it is unac- 
countably set down as indicating an irritable uterus, and not an 
inflamed uterus. 

Diagnosis of Submucous Inflammation. — I think when I touch 
the uterus with the finger or an instrument, and the patient shrinks 
from the contact, and says " she is sore," or "it is sore," that 
there is inflammation there. Tenderness is not an evidence of 
mucous inflammation, but of submucous or fibrous inflammation of 
the uterus. And it is a matter of importance to determine the 
presence or absence of submucous inflammation either as an inde- 
pendent affection, or complication of inflammation of the mucous 



DIAGNOSIS. 215 

membrane. It is a great error to confine our attention to the 
abrasions or ulcerations of the mucous membrane, and to believe 
we must see those abrasions or ulcerations before we can admit the 
presence of inflammation. 

Complication of Mucous with Submucous Inflammation. — We 
should not shut our understanding to the fact that the uterus 
should be examined by the same diagnostic rules that govern our 
investigations of disease in other organs. Some authors tell us 
that ulceration results from inflammation of the submucous tissue, 
and others that the inflammation begins in the mucous membrane. 
I am sure that inflammation sometimes exists in both these tissues 
at the same time. In this case we shall have tenderness and hyper- 
secretion. At other times there is submucous without mucous in- 
flammation ; then we shall have tenderness without hyper-secre- 
tion. Again, we may have mucous without submucous inflamma- 
tion, when hyper-secretion without tenderness will indicate it. 
These remarks will fix the importance of these two symptoms as 
indicating the seat of the disease. 

Size of the Uterus ordinarily Increased — Exceptions. — The size 
of the organ would seem to be a good indication of the presence 
or absence of inflammation ; but this may vary very much under 
what would appear to be the same form of disease. In endocervi- 
citis, it is usual to find the cervical canal increased in calibre ; but 
this is certainly not always the case, as I have met with unmis- 
takable instances in which this cavity was increased in size and the 
os uteri almost closed ; it was so small as to admit only a very 
small probe. Where there is mucous inflammation of the cervix 
extending toward the cavity of the body, and more particularly 
where the disease extends into the cavity of the body, the whole 
organ is likely to be enlarged. So much enlargement sometimes 
takes place, that the fundus may be felt considerably above the 
pubis : neither is this always the case, however ; often there is no 
enlargement. This hypertrophy, or general enlargement of the 
organ, is more frequently indicative of mucous than submucous or 
fibrous inflammation. 

Atrophy as the Result of Inflammation. — In fact, I think that 
long-continued inflammation of the substance of the body and 
cervix often brings about atrophy, or shrinking of the uterus. 
Permanent increase of size, or hardness of the cervix, must be 



216 DIAGNOSIS. 

the results of submucous inflammation, and generally coexist 
with it. 

Examine for Complications. — Some, if not all, of the pelvic or 
local symptoms, or such as much resemble them, may be produced 
and perpetuated without inflammation of the uterus ; hence it is 
necessary to examine the case with reference to this fact. We 
shall also occasionally find that, notwithstanding the complete cure 
of actually existing uterine inflammation, the local symptoms, in a 
modified form, still continue. These circumstances will be found 
to depend upon the independent or coexistent presence of some of 
the complications I have described. 

Cystitis as a Complication. — Chronic cystitis, rectitis, prolapse 
of the rectum, piles, urethritis, cellulitis, &c, &c, are among the 
most common causes of these symptoms. It is only necessary to 
mention these facts to enable the intelligent practitioner to explain 
anomalous cases that occasionally occur. There can be no doubt, 
I think, that holding the uterus to a rigid accountability for all 
the pelvic symptoms enumerated as the ordinary result of its dis- 
eases, has caused a good deal of confusion, and has enabled certain 
writers triumphantly to assure their adherents that in a number of 
cases the symptoms were present, but the ulceration was absent. 
A number of organs commanding extensive sympathies, sensitive 
under inflammation, crowded together in so small a space as the 
pelvis, supplied to a great extent with branches from the same 
nerves and arteries, must all be more or less congested, inflamed, 
and pained together ; and nothing but an intelligent and deliberate 
physical examination can make out the difference in their relative 
suffering, or certainly ascertain which of them is affected when one 
alone is diseased. 

Almost the only disease with which chronic inflammation and 
ulceration of the cervix uteri are likely to be confounded, is cancer 
in some of its stages. The many well-marked symptoms and phys- 
ical conditions which accompany this last disease are now, how- 
ever, so well understood and so thoroughly described, that the 
novice need not be embarrassed in his diagnosis of it. 

I find in Becquerel's "Traite Clinique des Maladies de Uterus," 
pp. 320-323, vol. i, so complete and faithful a diagnostic sum- 
mary between cancer and the different conditions of chronic inflam- 
mation of the cervix, that I have given its substance for the con- 
cluding portion of this chapter. It is subjoined. 



DIAGNOSIS. 



217 



Cancer in the Scirrhous Condition. 

Cervix hard, unequal ; nodulated, os 
not always open, sometimes wrin- 
kled or furrowed. 

Scirrhus of the neck often implicates 
the vagina. 

Hereditary influence is often tracea- 
ble. 

Touch is painless. 

Discharge sometimes absent, in cer- 
tain cases very abundant, and con- 
sisting, for the most part, of albu- 
minous serum. 

Menstruation increased, being neither 
more nor less painful, and passing 
often into the state of real hemor- 
rhage. 

Absence of special anaemia when the 
vagina and body of the uterus are 
involved. Cancerous cachexia. 

Progress continuous and without ces- 
sation. 

The pain in cancer is very sharp, in- 
tense, and lancinating, and not in- 
fluenced by locomotion or move- 
ments of any kind. 

Ulcerated State. 

Developed at the critical period of life 
generally. 

Preceded and accompanied by hemor- 
rhages. 

Severe, sharp, lancinating pain. 

Development essentially in sharp ir- 
regularities and nodosities. 

Adhesions to other organs soon as 
ulceration is formed ; immobility of 
the uterus. ■ 

The surface only slightly soft, subja- 
cent tissue scirrhous. 

Ulceration deep, unequal, essentially 
irregular, with thick, elevated, and 
hard edges. 

Always granulations. 



Inflammation with Ulceration. 

Neck less hard, developed regularly 

in one of the lips, os always open. 

The induration of the neck never ex- 
tends to the vagina. Mobility of 
uterus complete. 

No hereditary influence. 

Touch painful. 

Discharge constant and characterized 
by the presence of transparent mu- 
cus, muco-pus, or purulent mucus. 

Menstruation more painful, often re- 
tarded, almost always scanty. 



Special anaemia as above described. 



Often stationary for a long time. 

Pains less severe, more dull, and per- 
ceptibly influenced by walking and 
other sorts of motion. 



Chronic Inflammation and Softening. 
Occurs earlier in life almost always. 

Not preceded by hemorrhage. 

Pain dull and profound. 
Enlargement regular and rounded, or 

regularly lobulated. 
Complete absence of adhesions to other 

organs. Entire mobility of the neck 

and body of the uterus. 
Tissue of the cervix not hard, and 

easily destroyed. 
When ulcerations exist, less deep, with 

tumefied edges. 

Granulation often accompanies the 
other lesions. 



218 



DIAGNOSIS. 



Ulcerated State. 

Discharges extremely abundant, con- 
sisting of purulent and often sangui- 
neous serum ; nauseous and often 
fetid odor. 

Great hemorrhage from time to time, 
not necessarily at menstrual period. 

Cancerous Ulceration. 
Developed upon an hypertrophic and 
scirrhous surface. 

Ulceration deep, vast, unequal, gray- 
ish surface with thick edges, and 
easily bleeding. 

Ulcerated surface hard, presenting 
numerous lobes and tubercles, with 
nodosities and great hardness. 

Often great loss of substance. 

Cervix and corpus uteri immovable, 

on account of adhesions. 
Discharges sanious, fetid, sanguino- 

lent, and of an insupportable and 

characteristic odor. 
Cancerous cachexia always present. 



Chronic Inflammation and Softening. 
Discharges less abundant, consisting of 
muco-pus alone, or accompanied with 
a little blood, without odor. 

Always hemorrhage, but often a mere 
prolongation of the menstrual dis- 
charge. 

Simple Ulceration. 

Ulceration often on a healthy tissue, 
or presenting the soft or hard varie- 
ties of inflammatory injection. 

Ulceration more superficial, the edges 
less developed, and more regular at 
the bottom, not always easily made 
to bleed. 

Nothing of the sort in chronic inflam- 
mation and ulceration. 

Ulceration is not always accompanied 

with loss of substance. 
Neck and body always movable. 

Discharge of muco-pus or purulent 
mucus ; always less abundant. 

Special anaemia. 



CHAPTER XVIII. 

GENEKAL TBEATMENT. 

General Treatment. — I am sensible of the great difficulty of 
properly estimating the value of any given remedy or plan of 
treatment for the cure of disease. Nature does very much some- 
times to aid imperfect means, and even to effect a cure under im- 
proper treatment, while at other times the circumstances insepa- 
rable from a case thoroughly thwart the best directed efforts ; and 
very often we record cures and attribute great efficacy to our plan 
of management, when the favorable termination is due alone, and 
perhaps in spite of us, to the natural conservative energy of the 
system or the parts concerned. It is a mistake, therefore, to be 
too sanguine in our expectations even with the use of our favorite 
course of treatment, or to depreciate everything which has not 
fulfilled our hopes. We should patiently, honestly, thoroughly, 
and judiciously try every means within our knowledge for the 
benefit of our patient, let him labor under whatever disease he 
may. The reader is doubtless perfectly aware of the very great 
differences of opinion in the profession as to the treatment most 
beneficial in inflammation of the cervix uteri and its accompany- 
ing ailments. In alluding to these many and diverse opinions, I 
must record my conviction of the honesty with which they are 
maintained by the principal disputants of the present day, and 
most exhort the junior members of the profession to cautious and 
thorough research on the subject. There must be a right and a 
wrong side to every disputed question ; and, as a general thing, 
extremists are wrong ; remembering this general truth,- — we can- 
not always be kept in doubt by the facts in the case, if, without 
prejudice or party bias of any kind, we earnestly set to work to 
learn. 

Spontaneous Cures.— Are there any spontaneous cures in these 
cases ? I think there are, and I propose inquiring into the method 
adopted by nature, and take it as a guide to some extent, at least, 



220 GENERAL TREATMENT. 

for the plan of artificial treatment. Change of circumstances 
frequently makes robust persons of invalids. This change is gen- 
erally from irregular habits of living to regular and appropriate ; 
from the highest state of luxury and ease to one of need, or at 
least economy and industry, in which the patient must exercise 
her mind and muscles to a proper degree. The healthy tone of 
the stomach, muscles, and brain thus brought about decreases the 
susceptibility to slight suffering, enables the patient apparently 
entirely to recover from disease, and bear small ills without com- 
plaint. I need not specify the various circumstances and con- 
ditions of life which improve the tone and elevate the functional 
activity of the whole organism ; they are numerous, and will sug- 
gest themselves to the reader. How many journeys are taken, 
how much time spent at watering-places and places of amusement 
for this purpose ? And often they answer the purpose, and the 
patient is restored to health. 

Change of General Circumstances only Temporary in their Effect, 
— This improvement, in cases of disease of the uterus, is brought 
about rather by diminishing the nervous susceptibility to the wear- 
ing influence and pain of the local disease, and by fortifying the 
system against its advance by establishing excellent general health, 
than by actual cure of the ulceration and inflammation. As a con- 
sequence we find a return to the former mode of living, habits, and 
circumstances reproduces more or less rapidly the same train of 
general symptoms, and makes it necessary to resort to a repetition 
of the journey, or whatever other means were previously successful 
for their removal. This is only an apparent, not a real cure, and 
I hope I will be excused for saying that such is the kind of cures 
which always result from an exclusive general treatment. Tonics, 
laxatives, and alteratives put the general condition of the patient 
on a better footing, and the patient suffers less from her local dis- 
ease, and even considers herself well ; but suspend the general 
roborant appliances and the patient again sinks into her former 
state of valetudinarianism. I have often witnessed these changes 
as the effect of accidental mutation in the condition of the patient, 
intentional changes of place and circumstances, or well-advised 
general treatment. 

Supervention of Acute Inflammation. — There is, however, an- 
other method resorted to by nature, and which sometimes results 



GENERAL TREATMENT. 221 

in permanent and complete cure. Chronic inflammation has very 
little tendency to spontaneous subsidence ; its duration is at least 
indefinite. Situated in the neck of the uterus this is, particularly 
the case. Acute inflammation, however, on the contrary, has a 
strong tendency to terminate in resolution, to subside and leave 
the parts in a healthy condition. And, in cases of chronic inflam- 
mation in any of the organs, the supervention of the acute form 
proves sometimes salutary. It absorbs the whole chronic action 
and takes its place in the tissues ; and as it subsides, the diseased 
organ is left in a healthy condition. We have an opportunity of 
seeing this process of usurpation, displacement, or whatever else 
it may be termed, in diseases of the eye, and witnessing the salu- 
tary sequence. 

Acute Inflammation after Parturition or Abortion sometimes 
works a Cure. — Some of the functions of the uterus when natu- 
rally performed are followed by acute inflammation in the neck of 
the uterus. I allude particularly to parturition ; and while these 
inflammations sometimes linger and become themselves chronic, 
they generally under favorable circumstances subside kindly, and 
where the cervix had previously been affected by chronic inflam- 
mation, sometimes favorably modify, if not entirely cure it. I 
think that very few cases of parturition occur that do not cause 
sufficient violence to the cervix and os uteri, to be followed by a 
greater or less degree of acute inflammation. A great many are 
certainly thus followed by inflammation. The acute inflammation 
resulting from abortions occasionally has the same effect. I hope 
there is no danger of being misunderstood. Instances have oc- 
curred in the hands of most experienced practitioners where the 
uterine health of a primipara has been benefited by pregnancy 
and the processes of parturition. 

Principles of Local Treatment. — The local treatment of these 
inflammations is founded on the same principle of these natural 
cures. In the case of obstinate inflammation of the eye, we often 
resort to strong stimulants to modify a chronic inflammation, i. e., 
turn it into a moderately acute one, which, usurping the place of 
the chronic, causes it to subside, and leave the organ sound. And 
we know how successful it often is. So with the local treatment 
of inflammation of the cervix uteri. We awaken an acute inflam- 
mation in the tissues occupied by the chronic ; and, as the former 



222 GENERAL TREATMENT. 

subsides, the disease is favorably modified, if not entirely cured. 
This is a radical cure, where a sufficiently strong impression is 
produced either by the natural or artificial process. 

Physicians array themselves in two divisions in the treatment of 
uterine diseases. One division comprises those who consider the 
local disease as unimportant effects of the bad condition of the 
general health, who pay particular attention to the general condi- 
tion of the patient, and who give but little, if any, local treatment. 
While the other division relies upon local treatment for the cure, 
and the general merely as accessory. Those who look upon the 
local as the essential treatment, are also somewhat divided as to. 
the kind of treatment. One of these subdivisions thinks that if 
the uterus can be placed and sustained in its proper relative posi- 
tion to the other organs the inflammation will spontaneously sub- 
side ; while the other party believes in the use of strong stimulants 
and caustics applied directly to the diseased parts. I shall not at 
present pay much attention to the plan of mechanical support, 
leaving it for a future chapter, but will proceed to give the gen- 
eral and local treatment which can be relied upon with most con- 
fidence for the relief of patients affected with inflammation of the 
cervix uteri, and I shall first give the general treatment. 

Posture, Exercise, and Repose. — The young practitioner will 
soon learn that posture and exercise are important considerations 
in the general treatment, and he will be taught by most writers 
that the reclining posture and strict quietude must almost univer- 
sally be observed. Walking generally causes an increase of pain, 
and, it is natural to suppose, an increase of inflammation ; so that 
exercise on foot or in the erect position is regarded as injurious. 
On the other hand, confinement to the recumbent posture and the 
observance of strict quietude is very hard upon the general health ; 
the patient becomes more nervous, and all her functions are per- 
formed in an irregular and imperfect manner. As a consequence, 
in very many instances, the symptoms are much aggravated. In 
the great majority of these cases, therefore, I think the patients 
are injured by confinement and recumbency. It would neither be 
scientific, sensible, nor successful, however, to lay down any abso- 
lute rule in respect to exercise and quietude. I think we may 
arrive at pretty accurate conclusions as to the sort of cases and 
the conditions under which each should be observed. More than 



GENERAL TREATMENT. 223 

ordinary acuteness of the symptoms, indicating a high degree of 
inflammation, occurring in the beginning and continuing through- 
out, or arising during the progress of a case as the .effect of tem- 
porary causes, will make rest indispensable to the removal of them. 
Hemorrhage at the time of menstruation, or between the menstrual 
periods, is also a reason for strict quiet. Where neither of these 
conditions is presented, I think the patient will in most cases be 
much benefited by judiciously directed exercise. I feel like in- 
sisting upon the enforcement of outdoor exercise as the rule in 
these cases; for I have often had an opportunity of contrasting, 
in the same cases, the influence of quiet and exercise upon the re- 
covery of patients of delicate nervous constitutions. One patient 
who had been unable to sit up for even a short part of the day for 
several months, on account of the pain in the hips, dragging in 
the loins, and great nervous prostration, was sent to a water-cure, 
and in three months she returned home capable of walking several 
miles a day, and enjoyed comparatively robust health. In a few 
weeks after returning to a home in which she enjoyed the luxuries 
and ease so desired by all who prize good living, she became 
"miserable," and was obliged to abandon her exercise entirely. 
It is encouraging to state, that in less than six months of proper 
local treatment, she was permanently cured. This is but a type 
of many similar cases that have been benefited by the enforcement 
of exercise and other items of proper living, but, I must also add, 
not cured. It has been my constant aim for many years to induce 
patients of this kind to take as much exercise as they can bear. 
Under the mistaken notion that any local pain indicates an aggra- 
vation of their disease, and that to exercise when it gives them 
pain, even to a moderate amount, is a great evil, they confine 
themselves to their room, and even their bed, to the forfeiture of 
the healthy tone and energy of the nervous system which shield 
them from the intolerable and inexpressble ennui, melancholy, 
and irritability, which are so characteristic of bedridden women. 
Pain and weariness, that subside after a few hours' rest, should 
not be regarded ; it is only in those cases in which the pain and 
weariness increase at every effort at exertion that exercise should 
be abandoned, and then we should insist upon its being resumed 
again as soon as sufficient advance in the cure has been made to 
justify another attempt. We should not tire, during the whole 



224: GENERAL TREATMENT. 

treatment, in our endeavors to institute a system of regular and 
gradually increasing exercise, on account of the consideration that 
it is indispensable to the enjoyment of useful and comfortable 
health. Selection of the kind of exercise will depend, of course, 
upon the condition of the patient in respect to pecuniary matters 
as well as the state of her disease. Fortunately, the best kind is 
such as is within the reach of every kind of patients, not except- 
ing those who are under the necessity of earning a living. The 
capacities and demands of our nature are formed to answer the 
curse pronounced against Adam. We not only earn our bread by 
the sweat of our brow, but the labor necessary to procure the 
bread brings almost all the conditions that insure health and hap- 
piness. It is, in fact, a great evil of the present state of society, 
that our ladies cannot find in useful employment that healthy 
tonic exercise for the body and mind which they need, and that 
such exercise and employment are allowable and acceptable only 
in amusement. There is almost no variety in mental and corpo- 
real exercise required by the highest social amusements, and it is 
only when we descend to the primitive sports that our demands in 
this respect are met. It is undignified in ladies to fish, hunt in 
the woods, or engage in muscular feats. They must for muscular 
exercise engage in the measured sameness of the quadrille, or the 
giddy whirl and violence of the waltz, or cramp their limbs to the 
steady routine of a system of calisthenics. What are all these, 
for variety and adaptedness to their wants, compared to the wash- 
ing, ironing, sweeping, milking, churning, spinning, weaving, cook- 
ing, walking, running, of household engagements ; the stimulus of 
need ; thinking of all these things ; timing them ; proportioning 
them ; calculating, economizing, nursing, doctoring, advising, cor- 
recting, teaching, and conducting little minds and bodies through 
the physical, moral, and intellectual discipline which capacitates, 
unfolds, and imbues them with what is good and useful ? Woman's 
duties, taking them altogether, when well and appropriately per- 
formed, will do more than all the amusements that can be invented 
to keep woman well and healthy in every particular. In fact, it 
is only woman thus employed that can enjoy amusements. To the 
woman that seeks constantly after amusements, these very amuse- 
ments become an irksome and toilsome business ; they have a dis- 
agreeable sameness, and do not divert her; they simply vitiate her 



GENERAL TREATMENT. 225 

tastes. We all want variety, and constant employment, with a 
sense of usefulness attached to it. With this view of the useful- 
ness of mental and bodily labor, I encourage my patients to engage 
in their domestic duties and labor, gauging the amount of labor by 
their capacity of endurance. Attention to the homes of wealthy 
women, as society is now constituted, requires a great deal of 
anxiety and mental exercise. Without a proper variety of mus- 
cular exercise, the woman, in attending to the duties connected 
with it, becomes more nervous ; but the home of the poor indus- 
trious citizen or farmer gives enough and a healthy variety of both 
muscular and mental exercise to promote health and happiness. 
Should there be such objection in any shape as to make this course 
impracticable or improper, it is an interesting question to decide 
what sort of physical exercise is most desirable and beneficial. I 
am decidedly in favor of exercise on foot, outdoor, as one of the 
very best kind, far preferable to carriage riding or horseback. The 
carriage riding is not sufficient exercise for the most of such. 
patients, and yet those who are most debilitated, and utterly un- 
able to walk, may be much benefited by riding in an open car- 
riage until they become vigorous enough to walk, when it should 
be abandoned. Convalescent patients may ride on horseback if 
they can have an easy-going animal ; but this sort of motion is too- 
violent ; there is too much jolting for such cases until nearly or 
quite cured of the local trouble. We ought to induce our patient 
to walk more each day than the previous one, if possible, until 
she has plenty of exercise. 

Diet. — Unless during acute suffering, or on account of dyspepsia 
in some shape, a good substantial or nutritious diet should be al- 
lowed ; and sometimes we may, with propriety, allow stimulating 
drinks ; but as an ordinary thing, these last should be dispensed 
with entirely. 

Sexual Intercourse. — Young physicians have often asked me 
whether sexual intercourse is injurious during the time of treat- 
ment, and whether it should be permitted. I have no hesitation 
in insisting upon entire abstinence from this act. The recovery of 
our patient will be more rapid, certain, and complete, when this is 
observed ; and I believe that failures are the result of carelessness 
in this respect. It is very common for our patients to enjoy more 
comfort when absent from their husbands ; and come home from a 

15 



226 GENERAL TREATMENT. 

journey, as they think entirely cured, to be assured of the con- 
trary, by the first effort at coition, and become miserable with 
pain, nervousness, &c, in a short time, on account of indulging in 
this conjugal act. I desire therefore to be explicit in warning my 
young friends in the profession not to omit the interdiction of 
sexual intercourse, however delicate the task. A private interview 
should be sought with the husband for that special purpose. 

Main Objects of General Treatment. — The main object to be 
gained by general treatment, is to palliate the general condition 
of the system, to aid the local in effecting the cure, and to remove, 
when practicable, the effects left after a cure of the local disease. 
A cure of local chronic disease, by general treatment alone, is 
hardly to be expected ; although, in some instances, it may be in- 
dispensable to such result. When general treatment is used as a 
palliative or adjunct in local diseases, it is directed to the relief of 
general symptoms attendant upon them. It will be impossible 
for me to notice the treatment necessary in all the symptoms 
which attend and add to the distress of our patients in uterine 
diseases ; but there are certain prominent and troublesome ones, 
on which I cannot with propriety omit to dwell. I do so the more 
readily, from the embarrassment which I know, from experience, 
fills the mind of the inexperienced, as to the proper value to place 
upon general treatment, and the course to be pursued. 

General Symptoms requiring Special Attention. — The symp- 
toms, the treatment of which I propose to speak of in detail, are, 
1st, general nervous prostration ; 2dly, nervous excitability, exal- 
tation of nervous excitement ; 3dly, anaemia ; 4thly, general pleth- 
ora ; 5thly, local plethora ; 6thly, constipation : 7thly, indiges- 
tion. These are generally more or less complicated with each 
other, and sometimes several of them coexist ; but, ordinarily, 
some one assumes the most prominence, and occasions most dis- 
tress, and consequently requires more of our attention than the 
others. 

Nervous Prostration. — There is often great nervous prostration, 
and a sense of weakness, when, so far as we can judge, haemato- 
sis and nutrition are usually well performed. What is the cause 
of this depression must be sought out in each case, as there is no 
uniformity in the functional deviations. Very frequently there is 
a deficiency of menstrual discharge, the scantiness being very ob- 



GENERAL TREATMENT. 227 

vious ; at other times it is too copious. We should inquire into 
the functions of all the important organs, and correct them when 
disordered, as nearly as possible, by changing the habits and cir- 
cumstances of the patient, and afterward, or in connection, address 
remedies to the organs themselves. The stomach, liver, bowels, 
skin, kidneys, and uterus, should furnish their discharges in the 
most natural manner ; and if they are not doing so, should be cor- 
rected by the most gentle means. If several of these organs are 
in a state of functional deviation from health, we should not ex- 
pect to correct them all at one time, but alternate our attention 
between them ; first, with our remedies influencing one, and then 
another. I insist here, with reference to the plan to be pursued, 
not to address all these organs, or even a large part of them, with 
medicinal agents at one time. There is no question, I think, but 
that complicated formulae often nullify themselves by containing 
ingredients intended for the liver, kidneys, and skin, which ought 
all to act about the same time. We should act upon each of these 
alternately, in quick succession, if we think best ; but let each 
organ feel the full impression of its remedy, before the blood and 
nervous energies are directed to another. In addition to this in- 
direct way of increasing the tone of the nervous system, it is nat- 
ural for us to look about for something that will act more directly. 
Our patient becomes so depressed, and suffers so much from terri- 
ble feelings of prostration, that her condition appeals to our sym- 
pathies for more direct and immediate relief. If left to them- 
selves, or the advice of injudicious friends, they almost always 
resort to stimulants, as whisky, ether, chloroform, ammonia, &c. 
In some cases only are these temporary remedies advisable, and 
when used, they nearly always leave the patient in a worse condi- 
tion than before they were taken. They are allowable only as 
necessary evils, and should be avoided when possible. These pa- 
tients are usually depressed mentally also, and much good may be 
done by operating upon their minds. A physician who enters the 
room with a cheerful countenance, and a pleasant and gentle bear- 
ing towards the patient, and who engages her in conversation, first 
about her case, and afterward about some favorite theme, will do 
more toward temporarily relieving the great nervous and mental 
depression, than all the ether and ammonia the stomach can be 
made to bear. Earnest and kind assurances that her symptoms, 



228 GENERAL TREATMENT. 

though causing her a great deal of suffering, are not of a serious 
nature, and will soon subside, act generally as a good cordial to 
the spirits and nerves. In paroxysms of excessive nervous pros- 
tration, despondency, &c, I have seen the tonic influence of very 
cold air do a great deal toward relieving them. These paroxysms 
generally occur in close and often heated rooms, — two conditions 
which should be removed. If it is cold weather, we should cover 
the patient to protect her, and let the frosty air — the colder the 
better — into the room, by opening all the windows and doors, and 
keep the room cleared of visitors. It will astonish anybody who 
has not observed the effect of a temperature near to zero, on those 
swooning hypochondriacs. A change almost immediately occurs 
for the better. If the air is not cold, it will still do much good to 
give it perfectly fresh to the patients in abundance. When able, 
they may be taken outdoors. This treatment introduces the 
natural stimulants, oxygen and cold, into the lungs, and brings 
them in contact with the nerves, and is more enlivening than medi- 
cine. How long the room should be kept open and cold, will de- 
pend upon the effect, but we should always, if possible, make these 
patients sleep in open, cold rooms. This is a very important item, 
which it will often require ingenuity as well as authority to en- 
force. These patients should live outdoors as nearly as possible, 
and be as much as they can on their feet. 

Food. — Their food should have reference to the condition of the 
abdominal functions entirely, and be regulated by them. There 
is generally great intestinal torpor, which should be removed if 
possible.* Good cheerful company, travel — if the patient will 
not employ her body and mind in domestic pursuits — temperate 
and reasonable diversions, and, above all, time and patience are 
requisite remedies. It is obstinate and chronic, and with the most 
judicious management will require time, if it does not vanish as 
the local treatment advances. 

Nervous Excitability. — Connected with it in some manner is 
great nervousness, excitability, irritability, or exaltation of all 
the nervous phenomena. This nervous irritability shows itself in 
great mental excitability, want of sleep, unreasonable agitation, 
restlessness, dissatisfaction; in short, in almost every phase of 

* See remarks on treatment of Constipation. 



GENERAL TREATMENT. 229 

mental, muscular, or nervous excitement. There is also excita- 
bility of the different organs, with or without general nervous- 
ness, palpitation of the heart, nervous headache, local muscular 
contraction, &c. Successful management of these nervous and 
excitable patients requires a careful scrutiny into their general 
condition ; the chylopoietic functions should be regulated in the 
most careful manner ; the skin and kidneys should be attended to 
with great watchfulness. All that I have said as to general man- 
agement in cases of nervous depression will apply to this kind of 
cases. As complete a revolution of the circumstances of the 
patient should be made as is practicable. From a life of ease, 
luxury, and absence of care, she should be, if possible, placed in 
circumstances requiring care, with muscular out-of-door exercise 
to the greatest extent she is capable of. If we cannot place our 
patients in situations which their cases require, we can send them 
on journeys that will require exertion, calculation, care, and the 
deprivation of their usual domestic luxuries. The remark is fre- 
quently made that we must temper our remedies to the delicacy 
of the patients; and I am afraid that this injunction is miscon- 
strued into the necessity of too great tenderness of treatment. 
The better rule is to make use of such means as will raise the pa- 
tient from her state of delicacy to robustness. It is the delicacy 
of her constitution that causes her to suffer so much. This can 
be strengthened only by proper physical, moral, and mental train- 
ing. The moral and mental condition of our patients when so 
very excitable should be attended to. Improper reading and so- 
ciety should be avoided, and social and literary habits should be 
reduced to great plainness and simplicity. Above all things, 
books and society should not interfere with regular rest, exercise, 
and outdoor exposure. As I have said before, this last should be 
as great in amount as can be borne, accompanied with active mus- 
cular exercise, as walking, and should be practised in all weathers, 
sufficient protection being secured by enough clothing of the right 
sort. With regard to the use of medicine, it is a fact, that it is 
an exceedingly difficult thing to find any remedy that does not 
produce exaggerated and in most cases disagreeable and even in- 
jurious effects. So much excitability of the nervous system nearly 
always modifies the effects of remedies, and we can seldom predict 
the operation of any of them, nor can we determine the value of 



230 GENERAL TREATMENT. 

any until it has been tried. When tonics can be borne, they often 
very much relieve and sometimes entirely cure this great nervous 
excitability. Of the mineral tonics, probably bismuth, arsenic, 
and zinc agree best. Iron is not frequently tolerated in any 
shape by these very nervous patients. Quinine, nux vomica, 
cherry and chamomile are the best tonics in these cases, but we 
must not be surprised if none of them are borne. Alcoholic 
stimulants in general agree with them, and are the best cordials 
for temporary nervous excitement, but should be conscientiously 
avoided when possible, as not a few, I am sorry to say, of most 
estimable and intelligent women have used them too much, and 
engendered an appetite that could not be denied. Opium, as well 
as the narcotics generally, fails to have any good effect, but on 
the contrary disagrees with the patient totally. This, however, 
is not always the case, as it acts like a charm with some. In all 
it should be studiously avoided as deleterious in the long run, and 
there is danger of creating an appetite for it. We may the more 
readily be persuaded to omit the use of all these medicines, as 
their effects are temporary, while hygienic and regimenal reme- 
dies are permanent in their effects. The management of those 
cases of localized nervousness or unnatural excitability in partic- 
ular organs, as palpitations of the heart, nervous headache, &c, 
is about the same as above, except that more attention to the stom- 
ach, from which they usually arise, may be necessary. 

Anosmia. — Anaemia, with its disagreeable concomitants, some- 
times also calls for separate treatment. It would be an unneces- 
sary waste of time and space to enter minutely into the general 
treatment necessary, where anaemia is the prominent and trouble- 
some symptom. This condition calls for the same treatment found 
useful under other circumstances, and while it may not be entirely 
amenable to, it will be very much benefited by the remedies indi- 
cated by the state of the blood. Iron, cod-liver oil, quinine, bitter 
infusions, and nutritious diet, with outdoor exercise to the extent 
the patient can bear, are the efficient remedies. 

Plethora. — But we sometimes find general plethora instead of 
anaemia, a state in which there is actually an unusual amount and 
a too rich composition of the blood. I need not dwell upon this 
general state of the system, as the treatment is simple and familiar. 
The great fear is that, on account of the painfulness about the 



GENERAL TREATMENT. 231 

hips and legs, the patient may be too much inclined to an inactive 
life. On no account should this class of patients be allowed their 
ease ; they must be urged to use up their surplus blood in active 
exercise, and the kind of exercise, next to the cares and labor of 
a household, best adapted to them, is walking. Every muscle in 
her body must be brought into action ; every secretion must be 
kept free, and her mind ought to be taxed to continuous effort 
during the day by some useful occupation, while the strictest 
temperance, with reference to ingesta, should be her rule of living. 
Obesity and the troublesome and dangerous effects of plethora 
will be thus avoided, connected or unconnected with general 
plethora. 

Local Congestions. — We sometimes meet with instances of vio- 
lent, dangerous, and even fatal determinations of blood to par- 
ticular organs, as the consequence of the general ill health which 
accompanies uterine disease, such as stupor, stertorous breathing, 
&c, indicating an oppressed condition of the brain, great dyspnoea, 
and sense of suffocation, showing congestion of the lungs. The 
treatment of these congestions does not differ from what would be 
appropriate under other circumstances of their occurrence, and 
consists in revellents, .alteratives, &c. The most frequent, and 
perhaps obstinate, of the local congestions, are such as occur in 
the chylopoietic viscera, manifested by excessive secretion and dis- 
charges from the stomach and bowels. It is not uncommon for 
these patients to have suddenly recurring attacks of vomiting, 
cramps in the stomach and bowels, diarrhoea, and consequent great 
distress. Aside from the local treatment, we will be called upon 
to exert our skill against the exhausting and depressing influences 
of these attacks. It will almost always be found that such attacks 
are preceded by constipation, with scanty secretions, furred tongue, 
and other evidence of unhealthy secretions. By carefully correct- 
ing this condition, we may avert these painful and exhausting 
occurrences. The plan recommended and so much prescribed by 
Abernethy, will often palliate very much, viz., six or eight grains 
of blue mass, at night, worked off by some saline cathartic in the 
morning of every fourth or fifth day. If there is more permanent 
diarrhoea, great care should be exercised in the choice of diet ; the 
use of warm baths should be recommended, very warm clothing, 
and not much medicine, as the cure will depend upon the appro- 



232 GENERAL TREATMENT. 

priate treatment of the local disease, instead of the treatment of 
the general symptoms. All these symptoms, except the diarrhoea, 
are apt to be moderate, and can be borne until the diseased uterus 
is cured ; but there are two symptoms so very annoying, and 
which require so much patience in the treatment, and exercise so 
much unfavorable influence upon the uterine disease, that I hope 
I will be pardoned by the reader for dwelling upon them more at 
length. 

Constipation. — I allude to constipation and indigestion, particu- 
larly the former. I have already spoken of the deleterious influ- 
ence of constipation, and I think I am justified in saying 1 that, if 
disregarded, it retards the cure of chronic diseases of the unim- 
pregnated uterus more than any other sympathetic affection. And 
I wish to warn the practitioner to be very particular in attending 
to this symptom. There is probably more tendency to costiveness 
in females than in males, chiefly owing to difference in habits. 
Sedentary life, confinement to close, badly ventilated rooms, are 
among the circumstances that bring on this condition. Irregu- 
larity of meals, late hours, deficient sleep, concentrated diet, im- 
perfect mastication of food, all should be corrected, as any one of 
them alone will do harm, and all or any of these combined — and 
this is frequently the case — are very deleterious to the functions 
of the alimentary canal. But an inexcusable and very common 
custom of most females is making the act of defecation a disagree- 
able and procrastinated necessity, instead of a pleasant and punc- 
tual duty. The most trivial excuse — the presence of friends, a 
little cold, hot, or wet weather, being among strangers, or a 
slightly inconvenient distance from a proper place — will fre- 
quently be sufficient to limit defecation to once a week ; then the 
act is performed in a hurried manner. It is amazing to know to 
what lengths this negligence is often carried. I have known two 
weeks to have transpired, frequently, according to the history of 
patients, without any attempt to relieve the bowels. Now this 
should be corrected by persistent method. The habit of eating 
from hunger at certain hours depends upon lifelong practice, and, 
when once established, cannot be changed without violence to 
many functions, causing urgent and repeated demands upon the 
system for a resumption of it. Regular bowels come from an 
equally long-continued habit of going to the close-stool at partic- 



GENERAL TREATMENT. 233 

ular hours of the day. Years of negligence destroy the habitual 
regularity with which the bowels move ; hence we should not be 
discouraged if the habit be not re-established without long perse- 
verance. A new habit cannot be formed, nor an old one altered, 
without long and persevering effort in the right direction. We 
should, therefore, encourage a patient that is in earnest in her 
search after health, to persevere for months, years, and indeed her 
whole life, if necessary, in going to her water-closet without fail, 
once every day, at a certain hour, as regularly as the clock points 
to it. This is indispensable to a correction of the bad habit of 
constipation. A very effective part of this regular endeavor is to 
cause the mind to dwell upon the necessity for an evacuation, and 
the process itself, for at least half an hour before retiring to the 
proper place. It is not a difficult matter, with many persons, to 
create a desire in this way. Let no consideration of convenience 
enter into this punctual effort at stool. Arrived at the proper 
place, the position should be an easy one ; no inconvenient strain 
upon any muscle should be allowed, and the patient should be pos- 
sessed with an entire sense of leisure to perform the act completely. 
The value of all these considerations, where faithfully followed, is 
incalculable, and very few cases can long resist them. Without 
them, medicine will only temporarily relieve, instead of perma- 
nently curing, obstinate cases. I should caution against severe 
effort, or straining, as it is called; let time, patience, and gentle 
effort be the plan. Another matter of great importance, when an 
effort is made to have an evacuation, is to have the abdomen dis- 
tended by ingesta. The patient should be instructed to eat plen- 
tifully of vegetable diet, such as by its bulk is calculated to pro- 
duce fulness. If the patient go to the water-closet with a sense of 
fulness of the abdomen, success will be much more likely. Should 
the regular time for making an effort be soon after breakfast, 
which is undoubtedly the best time, and the meal has not been 
sufficient to produce a sense of moderate distension, a full glass of 
water will complete that condition. For the purpose of giving ful- 
ness and a sense of distension, various kinds of ripe fruit may be 
resorted to with advantage. In prescribing fruit for constipation, 
we should bear in mind that there are three indications fulfilled by 
it, some kinds fulfilling all, while others fulfil only a part of them. 
They are, first and best, distension ; secondly, increase of secre- 



234 GENERAL TREATMENT. 

tion, on account of their acids ; and thirdly, increasing peristaltic 
action of the bowels by indigestible fibres, seeds, or rind. Ripe 
and mellow apples, without being divested of the rind, may be 
eaten in sufficient quantities to produce a sense of fulness, and this 
should always be at the conclusion of a meal, breakfast, for in- 
stance ; the acids will increase the intestinal secretion, and the 
rind quicken the peristaltic motion of the bowels by acting directly 
upon the mucous membrane, and through it on the muscular struc- 
ture. Very acid fruit, as lemon and orange, only produce their 
effect on account of the acids they contain. They are excellent 
as a part of the ingesta of patients whose stools are dry and hard 
and lumpy. Fruits containing an abundance of seeds, as figs, or 
of rind, as tamarind, &c, increase the peristaltic action without 
causing much secretion. By inquiring into the character of the 
stools, we will have a good guide as to the kind or mixture of fruits 
to be selected. There are kinds of diet, breads particularly, that 
act like these last fruits, and may be used in conjunction with or 
independent of them. Breads in which the bran, or hull of the 
grain, is contained in considerable quantities, are of this character. 
The Graham bread, as it is usually called, ordinary coarse brown 
corn or wheat bread, are those mostly resorted to. When this 
kind of bread is used for constipation, it should be eaten at break- 
fast, dinner, and supper, in such quantities as the experience of 
the patient finds necessary. I have advised patients who could 
not use the coarse breads, to make what may be called bran 
crackers. A tablespoonful of flour, one pint of wheat bran, two 
tablespoonfuls of white sugar, and water enough to make them all 
into a pasty mixture, are the ingredients. This mixture is made 
into cakes, small or large, as may be wished, and baked in an oven 
until hard. When soaked in tea, coffee, or milk, they are not un- 
pleasant. I have known patients benefited by swallowing certain 
seeds, with the rind whole. A tablespoonful of wheat grains, oats, 
barley, white mustard seed, &c, can all be used for this purpose, 
and are not more disagreeable than medicines. Another kind of 
diet which may be used to produce the kind of effect here aimed 
at, consists of the various small vegetables, as celery, radishes, 
pepper-grass, lettuce, asparagus, cabbage, &c. These may all be 
taken in quantities to cause distension. 

In speaking of fruits, I ought to mention the berries as an ex- 



GENERAL TREATMENT. 235 

cellent means, cheap and easily procured, to accomplish all the 
objects attained by other fruits. 

Everything should be done by habitual effort, exercise, diet, 
drink, &c, before resorting to the use of medicines ; because, as 
is well known to the patients generally as well as to the practi- 
tioner, the more medicines taken the more will be necessary. They 
lose their influence, and the dose must be increased in order to 
produce a full effect. This is almost always the case. Notwith- 
standing this evil, we are often reduced to the necessity of using 
laxatives to overcome constipation. To a just and intelligent 
application of medicines in the treatment of constipation, it is in- 
dispensably necessary to make ourselves acquainted with the con- 
dition of the alimentary canal with reference to its secretions and 
muscular powers. It will be found that there are sometimes great 
deficiency of secretion, and torpor or want of vitality of the mus- 
cular structure, or weakness of this tissue. The want of secretion 
may be in the upper portion, in which case the bilious color is 
wanting in the stools, Or the small intestines may give out less 
watery material, and then the stools are less fluid, or even dry. 
The secretions may also be deficient in the lower portion, or colon ; 
in which case the faeces will be scybalous, dry, and lumpy. The 
muscular torpor, from want of irritability, is more frequent in the 
colon or rectum than in the small intestines. When in the colon, 
there is increase in size of the lower abdomen, sense of fulness 
and hardness, and the faeces are expelled with great difficulty. If 
there is sufficient activity of the colon, but the rectum is torpid, 
large accumulations occur there, the pelvic distress is increased, 
and nervousness, general and local, is exceedingly annoying. 
Sometimes all these conditions are combined to render the case 
one of the most troublesome and difficult to manage. Mechanical 
obstruction by stricture of the rectum, formed by pressure of the 
uterus, may give rise to chronic constipation, which may become 
permanent and almost incurable ; or the uterus, by lying on the 
bowel and pressing it against the sacrum, often gives rise to cos- 
tiveness, that can be removed only by correcting the position of 
that organ. It is not sufficient to know that the patient does not 
have regular operations from the bowels, but we must know why 
she is thus constipated. Whether on account of want of secretion, 
and if so, of what secretion ; whether it is attributable to general 



236 GENERAL TREATMENT. 

debility, combined with muscular weakness of the intestines; 
whether to lack of irritability of the intestinal tube and consequent 
torpor, and if so, where is this lack of irritability ? Does it exist 
in the whole length of the canal, in the colon, or the rectum ? Or 
whether there is obstruction from stricture in the rectum, piles, thick- 
ening of the mucous membrane, rigidity of the sphincter, or pres- 
sure from the uterus bearing so heavily upon it. To give a laxative 
merely because it ordinarily produces a fecal discharge, is always 
unphilosophical, and sometimes exceedingly injurious in its effects. 
I think it is inattention to the exact state of the alimentary canal 
that makes constipation so often incurable. For constipation, 
attended with very dry, hard stools, showing a deficiency in all 
the secretions from the bowels, in addition to the course of diet, 
including acid fruits, &c, our object should be to administer such 
drugs as will most effectually stimulate to secretion. The various 
saline medicines are indicated. Sulphate of magnesia is a most 
excellent one, and a good way of administering it is in combina- 
tion with sulphuric acid. From one to two drachms, or even half 
an ounce, given in combination with acid enough to taste some- 
what sharply, will promote secretion along the whole of the small 
intestines, cause a large effusion of water, which will dissolve the 
faeces and render their evacuation easy and sure. In the morn- 
ing, some time before eating, is the best time to take it. When 
there is reason to believe that the portal circulation is slow, and 
the liver furnishing less than its usual amount of secretion, some 
form of mercurial should be used with the salts. If the case is 
chronic and the constipation obstinate, we may give six to ten 
grains of blue mass, in pills, at bedtime every fourth or fifth 
night, and follow it with Epsom salts in the morning. A con- 
tinuance of this alterative cathartic for four to six weeks seldom 
fails to cause a change in the alimentary secretions. Sometimes 
it is better to give these cathartics nearer, and sometimes farther 
apart. We must judge of this more by the susceptibility to the 
constitutional influence of mercury than anything else. It is 
almost always the case that this very scanty state of the secre- 
tions is accompanied with an impoverished state of the blood ; 
hence iron in some shape will be beneficial in most cases. If 
there is much debility, a long course of tonics will be indispen- 
sable. It may often happen that this scanty condition of the 



GENERAL TREATMENT. 237 

secretions is attended with debility of the muscular fibre of the 
intestinal canal. When this is the case, we must add to the above 
treatment that which is applicable to this kind of intestinal torpor, 
which I shall not consider. Before doing so, however, I will 
remark that several other salts will answer as well, and sometimes 
even better, than sul. magnesia. The kind of tonics which are 
most effectual in debility of the muscular structure of the intestinal 
canal are such as give general strength, and it is mostly desirable 
to combine them with special tonics. The later are rhubarb and 
nux vomica. These have always seemed to me to have a special 
tonic influence upon the intestinal tube, and, when properly given, 
to increase the susceptibility to their own action. The rhubarb, 
although an alimentary tonic, induces less susceptibility to its 
own influence than the nux vomica. The best way to give the 
rhubarb is either in the root, without pulverization, or in the 
extract. When given alone in the root, the patient can take a 
little twice a day, by chewing it, and after mixing with the saliva 
swallowing it. A little experience will enable the patient to judge 
of the right quantity, which she can repeat as 'often as it is re- 
quired. When the rhubarb is taken in this way, she may also take 
a solution of sul. ferri and strychnia, in water, one grain of the 
former to one-sixteenth of a grain of the latter. 

A formula that is very simple and effective is as follows : 

&. Strychnia, gr. j. 

Ferri Sul., ... .... gr. viij. 

Acid Sul., q. s. 

A( l u a, -fij. 

Mix. Make solution. One teaspoonful three times a day after eating. Six- 
teen grains sul. quin. may be added to the above formula with advantage. Or. 

R. Strychnia, gr. j. 

Ext. Ehei, J}iss. 

Sul. Ferri, ....... gr. x. 

Mix. Make sixteen pills. One to be taken once, twice, or three times a day, 
as may be found necessary. 

I have often succeeded in overcoming this constipation or de- 
bility by giving one grain of sul. quin. with five grains of pow- 
dered nux vomica after each meal. Or the same amount of nux 
vomica, with iron by hydrogen, two grains, after eating, each 



238 GENERAL TREATMENT. 

time. It is usual to use aloes in the constipation of uterine dis- 
eases; but I have found very few cases with which this drug did 
not disagree. But there is a torpor of the intestines where gen- 
eral tonics cannot be borne; where, in fact, there does not seem 
to be any general debility, — there is only a want of susceptibility 
to the stimuli which ordinarily arouse them to action. The secre- 
tions color the fseces properly and give them sufficient moisture : 
there seems to be no fault in their appearance, consistence, odor, 
or other character whatever. They are deficient only. The pa- 
tient may be plethoric and florid, her general muscular strength 
sufficient, and her blood, so far as we can judge, good in compo- 
sition. Special tonics and stimuli are indicated in such instances, 
and they alone should be used. Such measures should be adopted 
as will arouse the muscular action of the intestines. Nux vomica, 
in five-grain doses, with the rhubarb extract or without it, or the 
strychnia in solution, in sixteenth to twentieth of a grain doses, 
constitute our most valuable medicinal appliances. This is the 
kind of constipation that is most benefited and is most amenable to 
a persevering regimenal and dietetic course of management, such 
as I have above endeavored to give. In addition to the rhubarb 
and nux vomica treatment, we may get some good from external 
appliances and manipulations to the walls of the abdomen. The 
most valuable, when gently, perseveringly, and methodically ap- 
plied is what is understood by the term kneading. The colon is 
the torpid portion in most cases of this sort of constipation. The 
process of kneading consists in handling it so as to stimulate its 
fibres directly. One plan is to grasp it with the hand and squeeze 
it from one end to the other. We should begin at the right groin, 
and with a knowledge of the position and direction of it, grasp it 
with both hands at this point, then a little higher up on the same 
side, and then a little higher, until we reach the right hypochon- 
driac region. We should then follow it across the abdomen to the 
left hypochondriac region, and thence down to the left iliac. Or, 
we may double our hands as bakers do when kneading their dough, 
and standing over the patient, press with the knuckles of both 
hands, first in the right iliac region, and imitating the process of 
kneading, pass slowly from this to the right hypochondriac, thence 
across the abdomen and down as before directed. If we trust 
this process to a non-professional attendant, we should be sure to 



GENERAL TREATMENT. 239 

show how to do it, as it is important that it should be done right. 
When this process of kneading or squeezing the colon is first in- 
stituted, it should be practised with the utmost gentleness, but the 
force and rapidity of motion may be increased until great freedom 
may be made use of. It should be resorted to a short time before 
retiring to the water-closet, say half an hour. Some patients find 
an efficient laxative in what they sometimes call a water compress, 
applied to the abdomen over night. It is made by doubling a 
napkin several times, so as to make a thick compress, large enough 
to cover the entire abdomen anteriorly. This is saturated with 
water, and, after being placed upon the abdomen, covered with a 
roller or bandage so as to keep it in place. It is thus allowed to 
remain from the time of going to bed until the time to rise in the 
morning. I think this water compress is best adapted to cases in 
which there is a deficiency of secretion in the intestinal tube. A 
bandage, or, what is better, a roller applied tightly enough to press 
the walls strongly upon the contents of the abdomen, frequently 
stimulates them to proper action, both as it respects secretion and 
peristaltic motion. When it is determined to use the roller or 
bandage for its stimulating influence, it ought to be applied upon 
rising in the morning, or, what is perhaps better, immediately after 
breakfast. This bandage should not be worn constantly, nor even 
many hours in the day. From the time of rising until two hours 
after breakfast, or from breakfast for three hours thereafter, will 
be long enough. The constant use of the bandage would but in- 
crease the evil — lax abdominal muscles — for which it is advised. 
Before leaving this part of the subject, I desire to say, with refer- 
ence to the freedom with which I have advised nux vomica to over- 
come intestinal torpor, that in all cases we should remember its 
effects are cumulative, and quite a difference of susceptibility to its 
influence is manifested by different persons, in consequence of 
which the patient should be watched, and the dose graduated to 
the least quantity necessary in the case. Although I have given 
nux vomica and strychnia for a considerable length of time to a 
great variety of persons, and for several weeks together, I have 
never seen anything more than slight inconvenience from it in the 
shape of nervous startings. Very rarely we meet persons who 
cannot take it at all ; it disagrees with them as soon as they com- 
mence its use. — There is another species of intestinal torpor, of a 



240 GENERAL TREATMENT. 

very obstinate character and very distressing to the patient ; I 
mean a lax, torpid rectum ; so torpid as to allow the faeces to ac- 
cumulate in large quantities and cause great inconvenience from 
pressure. To such an extent does this collection sometimes go as 
to press the posterior walls of the vagina forward and protrude it 
between the labia. The first indication in such cases is to dissolve 
the fecal mass and discharge it. Various kinds of injections are 
useful for this purpose, warm oil, warm water, &c, but one which 
I have seen do much good is composed of one ounce of fresh ox- 
gall and four ounces warm water. This composition dissolves the 
faeces very readily, and the fresh bile stimulates the intestine to 
their expulsion. The evacuation of course will give only tem- 
porary relief, and there remains the most important indication, 
that of giving tone to the bowels, with a view of preventing the 
accumulation in future. This is difficult, and in some instances of 
long standing quite impossible. Much good can be done in nearly 
all cases, however, and we do not discharge our duty if we do not 
try to relieve when we cannot cure every case. Cold water thrown 
into the rectum once or twice a day, in small quantities, — eight 
ounces, — is always good, without some special reason to the con- 
trary. There are generally two indications to be fulfilled in these 
cases : relaxation of the sphincters and restoring the tonicity of 
the proper rectal fibres. It is a singular fact, which I think I have 
observed, that the sphincter muscles increase in strength with the 
advance of age ; this is one of the causes why the faeces are voided 
with more difficulty in old persons. To give tone to the rectal 
muscles, astringent injections have been recommended and exten- 
sively used ; but in my practice they have been almost uniformly 
useless, many times injurious, and always disagreeable. They dry 
up the secretions, an evil not to be compensated for by any other 
effect ; they do not, so far as I can judge, cause contraction of the 
muscular fibres, but they are very apt, if persisted in for a length 
of time, to cause inflammation. I have derived more benefit from 
tonic suppositories and injections than from any other kind of me- 
dicinal treatment. A suppository of twenty grains extract gentian, 
or five grains sul. quin., ten grains extract cornus florida, or a 
mucilaginous suspension of any of these, introduced into the rectum 
every night at bedtime, and retained if possible until morning, are 
good tonics and eligible modes of using them. It will be necessary 



GENERAL TREATMENT. 241 

to secure the retention and efficient contact of these tonics, to first, 
empty the bowels with ox gall and warm water, and afterwards in- 
troduce them with as little irritation 'as possible. The quantity of 
mucilaginous material should not exceed two ounces. The tonic 
treatment of this kind must be varied, taking first one tonic and 
then another, in first one form and then a different one, and must 
be kept up for a long time to do much good. We cannot be too 
careful in all our treatment, to avoid anything to which the rectum 
shows any sensitiveness. When it becomes tender and sensitive, 
we should at once desist until all of this has subsided before we 
are justified in beginning again.. It too frequently happens that 
both the physician and patient become discouraged, and desist be- 
fore the remedies have had a fair trial. 

Is there anything that will relax the sphincter ani ? I am not 
aware that any means operate with efficiency in this direction, 
but I have used, in a few instances, with apparent benefit, the 
ointment of belladonna, made by mixing the extract with lard. I 
apply it to the anus externally upon going to bed at night, and 
think that it promises decided encouragement to continue, until 
the question against or in favor of its usefulness is fully deter- 
mined. This is a good formula. 

J&. Ext. Belladonna, ^ij. 

Ung. Simplex, 3J. 

Mix. Make an ointment. The parts to be well smeared with it at bedtime. 

This application certainly removes the irritability of the sphinc- 
ter, which causes it sometimes to resist the extrusion of the feces. 
As I have before remarked, there are cases in which this relaxa- 
tion cannot be cured : we are then compelled to resort to pallia- 
tives, and we must be careful to palliate intelligently. We are to 
give the weak rectum artificial support, to enable it to retain as 
near as may be its ordinary size. This can be done only through 
the vagina. An air or sponge pessary introduced into the vagina, 
so as to press the rectum against the sacrum, and thus diminish 
its capacity, will prevent the great accumulations from taking 
place, and in that way prevent one source of great inconvenience. 
Dr. Hodge recommends the globe pessary for this condition of 
the rectum, which answers very well in many cases, perhaps in 
the majority ; but each case must be studied with reference to its 

16 



242 GENERAL TREATMENT. 

own peculiarities, and the shape, size, and consistency of the pes- 
sary adapted to it. When our object is palliation alone, there is 
no objection to wearing the pessary all the time, but if it is used 
to palliate what we believe to be a curable case, we ought to use 
it intermittingly, and the patient should not wear it at night es- 
pecially. It would probably be better in a majority of the cases 
to introduce it before rising in the morning, and allow it to re- 
main until noon. One thing I think essential in the size and po- 
sition of the pessary, and that is, that it does not compress the 
rectum below its natural capacity ; there should be room enough 
for an ordinary amount of fseces in it, lest it become a source of ob- 
struction, which it will do when larger or improperly placed. As 
will be noticed, I have omitted to say anything of enemata in 
constipation, from inactivity of the colon or upper portion of the 
alimentary canal. As an occasional means, injections operate 
well ; but, like other laxatives, when used for a length of time 
they lose their influence entirely. If we determine to use injec- 
tions as an habitual laxative, by proper changes in kind and quan- 
tity, we may prolong their efficacy very much. To a person un- 
used to them, half a pint of cold water will act very well. When 
the bowels fail to respond to this quantity, there ought to be an 
increase of two or three ounces, and then that amount used until 
its effects are not satisfactory, when a few ounces, more should be 
added, and so on we may increase the amount until the quantity 
becomes intolerable. When this is the case, we may order half a 
pint of water with a drachm or two of common salt, chlorate po- 
tassa, or nitrate of soda or potassa. We should increase the quan- 
tity of water or strength of solution, or both, as the susceptibility 
of the rectum decreased, until we cannot carry either farther. 
After we have thus obtained as much good from injections as we 
can, it is sometimes expedient to use suppositories as laxatives. 
Suppositories are made of laxative medicines or of any other ma- 
terial. Compound extract colocynth or other purgative extract 
may be used ; or we may inclose in some of the extracts a dose of 
the podophyllum, or any of the purgative resinoids or alkaloids. 
These should be retained until absorption takes place. The com- 
mon suppository of soap, tallow, and wax, sperm, stearine, &c, are 
of the second kind. It not unfrequently happens that the above 
modes of using injections and suppositories may be alternated very 



GENERAL TREATMENT. 243 

profitably, the full effects of each being experienced upon their 
resumption after having used the other for a time. But some per- 
sons cannot use injections; the rectum is too sensitive, and attempts 
to do so induce so much irritation that they must abandon them. 
In such cases suppositories are out of the question. 

I have elsewhere shown that the uterus, by its wrong position, 
sometimes presses upon the rectum and obstructs the passage of 
the faeces. This may be effected by retroversion or prolapse. 
The indication of course is to restore the uterus to its proper 
place, and as I shall have occasion to speak elsewhere of these 
difficulties (malpositions), I do not think it necessary to more 
than mention them here. 

Indigestion is another very troublesome condition among the 
many which attend uterine disease, and it will demand much of 
our attention. It would not be profitable to dwell at any great 
length upon this symptom, as it will become the duty of the phy- 
sician to study each case separately. Attention to the bowels, 
keeping them perfectly regular, will very much alleviate if it does 
not cure most cases; but sometimes we find the stomach very seri- 
ously disordered when the bowels are perfectly regular. In such 
cases we should inquire into the alkalinity and acidity of the urine 
as a good index for the administration of medicine. If the urine 
is highly alkaline, acids and bitters are indicated and will be well 
borne ; if the urine is highly acid in its manifestation, alkalies 
must be used, — liquor potassa, lime-water, soda, &c. In the for- 
mer case, animal diet may be tried ; in the latter, vegetable diet 
as likely to be good palliatives, and under proper circumstances 
curative. The indigestion, like most other symptoms, however, 
will be obstinate and generally incurable until after the local dis- 
ease is cured. It may be inferred from what I have already said, 
that I consider the general treatment, as I have endeavored to 
sketch it, of secondary importance, and the local as the essential 
treatment ; but wishing to be perfectly clear on this point, I will 
reiterate what I have already said in regard to the objects of 
general treatment. They are — 1st, To palliate the general condi- 
tion of the patient before and during local treatment ; 2dly, To 
aid local treatment in effecting the cure ; and 3dly, To cure the 
effects which may remain after the local disease has been removed. 
I do not believe that a cure is ever effected by general treatment 
alone. 



CHAPTER XIX. 

LOCAL TKEATMENT. • 

Baths. — The local treatment of inflammation of the cervix uteri 
is made up of several therapeutic items, varying according to the 
intensity, quality, and seat of disease. Of these there are, how- 
ever, a few that are applicable to almost all cases ; hence their 
description, modes of use, &c, may be considered before going 
farther. Baths, injections, and some minor remedies are of this 
kind. Water, when applied to the surface, is purely sedative in 
its effects if it is of the temperature of the part on which it is used. 
If the bath is partial, the sedative influence is for the most part 
confined or limited to the part to which the application is made. 
So with injections per rectum or vaginam. They sooth the parts 
contained in the pelvis. If the water is warmer than the part of 
the surface bathed, the effect is stimulant ; if it is colder, by virtue 
of the physiological action brought into play, it is first sedative 
and then stimulant. The circulation and nervous influence of the 
vagina, for instance, when the cold water is first thrown into it, 
are depressed, but very soon after its evacuation, or withdrawal, 
the vessels become excited to increased circulation of blood, and 
increased heat takes place and the nerves become more sensitive. 
In all these respects baths and injections act alike. The injec- 
tions are internal baths ; the uterus is bathed through the vagina 
by injections. But the effects of baths and injections may be 
modified by containing medicinal substances. They may be ren- 
dered more stimulant or more sedative, or be even made to 
possess other qualities by impregnation with medicines : one of 
which in very common use is astringent in character. Another 
mode of using water and applying it, either simple or impreg- 
nated with medicine, is to wet a cloth or a sponge with it and 
bind it to the surface, or introduce it into the vagina. Several 
thicknesses of cotton cloth applied to the abdomen and satu- 
rated with water is what is called the water compress ; and often 



LOCAL TREATMENT. 245 

when allowed to remain in contact with the skin for several hours 
it produces considerable excitement, and if persisted in for days, 
will cause first a vesicular, next a pustular, and finally a phleg- 
monous eruption. The way to render it effective is, after, ap- 
plying the wet cloth compress to cover it over with oil-silk, and 
then confine the whole with a bandage or roller, with a view to 
prevent evaporation. Sponge introduced into the vagina satu- 
rated with water holding some medicine in solution is a common 
way of affecting the uterus. I do not design giving an extended 
view of baths or their application and modus operandi, but so 
much aid is occasionally obtained by the use of baths, that I can- 
not refrain from speaking of the application of some forms of 
them to diseases of the uterus. The bath most applicable in in- 
flammation of the cervix uteri and most commonly used is the sitz 
or hip bath. It is intended to allay the inflammatory irritation 
and pain. It is often the case that there is a great deal of 
suffering from pain without much inflammatory action in the 
parts ; in these cases a sitz bath will often give great relief. In 
many instances the efficacy of the bath may be enhanced by hav- 
ing the patient introduce a speculum while in the water, so that 
it may pass up the vagina to the neck of the uterus, and thus 
directly affect the part diseased. In cases of medicated sitz 
baths, the organ may thus receive the full benefit of the saline, 
anodyne, or other medicinal impregnation. The common glass 
tube will do very well for this use, where we wish only to bathe 
the neck of the uterus ; but if we wish the fluid to come in con- 
tact with the vaginal walls and remain there for a considerable 
time, the wire speculum is the best. While speaking of the use 
of the speculum in this way, I may mention that a very effica- 
cious mode of applying medicated washes without the bath to the 
cervix uteri or vaginal walls, is to have the patient lie upon her 
back, introduce the speculum, and then pour the fluid into it. 
By remaining in that position she can retain the contact of the 
medicated solution as long as desirable. Ice-water, ice, astrin- 
gent powders, or almost any form of substance maybe applied 
and retained in contact with the os and cervix uteri with great 
advantage in this way. This mode of using remedies is particu- 
larly useful in bleeding fungus or vascular tumor of any sort. 
Eip Bath. — The sitz bath, when a patient is suffering with the 



246 LOCAL TREATMENT. 

pain and heat of uterine disease, may be used as often as neces- 
sary, twice a day at least ; but three, four, or even a greater 
number of times will not be too often, when they are found to be 
soothing and useful. We may extemporize a hip or sitz bath, by 
putting water in a common washing tub ; but the cheap vessels 
made for the purpose are within the command of almost all per- 
sons. There should be so much water that when the patient sits 
down in it, the whole pelvis will be covered. 

Temperature of the Bath. — What should be the temperature of 
the bath ? The patient's sense of comfort, or discomfort, from its 
use, should be our guide in this respect. We should seek a tem- 
perature that is comfortable and soothing to the patient, while in 
the water, and that leaves no sense of discomfort. The baths are 
intended for, and should add to the comfort of the patient ; when 
they do not do this, they should at once be discontinued. As a 
general rule, I advise my patient to' take tepid water for her first 
bath, and then gradually use them cooler until they are cold, un- 
less they become disagreeable in some respect ; if they do so, to 
continue them tepid. The colder a bath is, the more good it does, 
provided it be comfortable. The time for taking it may be regu- 
lated by the convenience of the patient, and the necessity for it, 
with the view of allaying pain, heat, &c. ; probably in the majority 
of instances, the most advisable times for taking it are upon rising 
and retiring. The length of time the patient remains in the bath 
should also be regulated somewhat by their effects. If the patient 
remain too long in the water, it will debilitate her, particularly if 
there is considerable water and the bath is frequently repeated ; 
on the other hand, if she does not remain long enough, she will 
not derive any benefit from it. She may try remaining in it fifteen 
minutes, if she does not find herself very much relieved before that 
time, and she ought to be governed in her use of subsequent baths 
in this particular by the effects of the first few trials. While in 
the bath, the intended temperature of the water may be kept up 
by adding hot water from time to time. The hip bath is used 
almost wholly with reference to the local disease, but when general 
baths are required, it is usually for the relief of some attendant 
general symptom. 

Shower Bath. — The shower bath may be used as a roborant ex- 
citor of the circulation, if upon trial it can be borne, and produce 



LOCAL TREATMENT. 217 

a good effect. Some patients think they are very much benefited 
by the shower bath, and say they cannot do without it. 

Sponge Bath. — The sponge bath is useful in causing a tonic and 
soothing reaction up^m the surface. Neither of these can be tole- 
rated by very feeble patients. The cold or tepid sponge bath, ad- 
ministered at bedtime, not unfrequently soothes nervous irrita- 
bility, and enables restless persons to sleep soundly. I have not 
used baths in any other form than these, but when used as I have 
here indicated, I have seen such pleasant results from them, that 
I cannot refrain from recommending them. 

Injections. — These are applicable to almost all cases of inflam- 
mation of the cervix uteri, do a great deal of good, and are be- 
lieved to be sufficient to cure some cases. As I have before said, 
they may be used as internal baths, to get the influence of water 
and temperature on the vagina and uterus, as the medium for the 
application of medicinal substances to the mucous surface of this 
cavity and viscus, and also as detergents, to wash the vagina of 
all substances that should be removed from it, for purposes of 
cleanliness. In some one of these forms injections may be used 
in nearly every sort of cervical inflammation. The simple injec- 
tion of water may, and ought to be used, by all females who have 
inflammation of the uterine neck. The medicated injections can 
be useful only in cases where the inflammation is within reach of 
them, as when inflammation affects the mucous membrane of the 
vagina, or the membrane covering the external surface of the 
vaginal portion of the cervix. For obvious reasons, injections 
containing medicines can hardly do any good, by virtue of the 
solution, when the inflammation is situated inside the cervical cav- 
ity. Vaginal injections cannot reach the seat of disease. I have 
not used intra-uterine injections, as I think there are less hazard- 
ous modes of conveying medicines into the cavity of that organ. 
The efficacy of injections depends very much upon the manner in 
which they are administered, and the kind of instrument used. 

Manner of Using Injections — Kind of Syringe. — The essential 
quality of a syringe is its capability of receiving at one end and 
discharging at the other perpetually, so that any quantity of water 
may be used without withdrawing and reintroducing the pipe. A 
large number of forms of syringe have been invented, but for con- 



248 LOCAL TREATMENT. 

venience, that form is, I think, preferable which has a vulcanized 
rubber hollow ball mounted in the middle of a long flexible tube; 
by pressing on this ball, and relaxing it, the water is drawn in at 
one end and forced out at the other. A pewter, britannia, or 
ivory tube delivers the water into the vagina, and by its length 
may be made to convey it to the uppermost part of that cavity, 
and thus completely wash the whole of its walls. A siphon may 
be made to answer the same purpose, by having the fountain high 
enough to give some force to the current. Should the patient use 
a syringe of the above description, she may sit over one vessel, 
and have the water in another in front of her. By inserting one 
end in the vagina, and the other in the vessel of water, the whole 
of it may be made to pass through the vagina and fall into the 
vessel beneath her, and thus* do away with the inconvenience of 
undressing. 

Quantity of Injection. — The quantity necessary to be used in an 
injection will vary very much in different sorts of cases; if water 
alone is to be used, and we wish to get the sedative influence, the 
quantity must generally be large, that is, from one to eight quarts ; 
if we wish to stimulate the uterus with very warm water, a large 
quantity will also be necessary; if we wish the injections cold, it 
is better not to use so much. 

Medicated Injections.— The medicated injections also should be 
large or small, according to the effect we wish to produce, and the 
strength of the solution. A pint, or at most a quart, will be suffi- 
cient for astringent injections. We often use anodyne injections 
on account of their soothing influence upon the sensitive parts. 
As a general rule, anodyne injections need not to be very large, 
say a pint, or less, but the patient can continue passing it through 
the vagina until its effect is attained. This may be done by using 
only one vessel, pumping from, and allowing it to fall into the 
same. Frequency must be determined also by the object of the in- 
jection. Simple water injections can be used more frequently than 
medicated ones, and anodyne more frequently than astringent. 
The simple injections, if they afford relief, may be used from three 
to six times a day, or oftener ; narcotics three or four times, or 
oftener, owing to the urgency of the symptoms requiring them, 
and the good they are found to do. 

Astringent Injections. — Astringent injections ought not to be 



LOCAL TREATMENT. 249 

made use of, as a general thing, oftener than twice a day, and in 
some cases to which they are applicable, this is entirely too often. 
Of all the vaginal injections used, the astringents are most com- 
monly resorted to, and are productive of most good. 

Modus Operandi. — When an astringent is thrown into the vagina, 
the first effect is to coagulate the mucus, pus, or blood contained in 
it ; after this, its contact with the mucous membrane becomes more 
intimate, and its influence is exerted upon the capillary blood- 
vessels, and the glandulse or crypts. The vessels are constricted 
in size, and circulate less blood, and the calibre and functional ac- 
tivity of the crypts are diminished, and little congestions and in- 
flammation are for the most part cured, or at any rate benefited. 
When the vessels are circulating too much blood, and the mucip- 
arous apparatus furnishing too much secretion, this astringency 
is desirable. We ought not, with certain exceptions, to use astrin- 
gent injections when there is no hyper-secretion from the mucous 
membrane of the vagina or cervix uteri, nor an ulcerated or in- 
flamed surface with which the solution can come in contact. The 
frequency with which they may be used must be indicated by ob- 
serving these two effects, and the dryness more particularly. 

Frequency of Using. — I think we may lay down a rule for re- 
peating them, like this : never repeat an astringent injection while 
the vagina is dry from the effects of a preceding one. We should, 
after obtaining the full astringency of an injection, in the stop- 
page of a leucorrhoeal discharge, wait until the mucus again ren- 
ders the mucous membrane moist. It will be found, very often, 
that this requires twenty-four and even thirty-six hours to' take 
place. A disregard of this direction will sometimes induce an in- 
crease of inflammation, and give our patient great inconvenience. 
In fact, too long a continuance of astringent injections is apt to 
cause vaginal inflammation. 

Alternate different Astringent Remedies. — I think, however 
much an astringent may be indicated, that the same article ought 
not to be used more than twelve or fourteen consecutive clays, and 
should then be alternated with another one of the same class, or 
simpler ones. This last I generally prefer. A permanent dryness 
of the vagina after any one astringent, should preclude the use of 
that article at least, and cause us to try another, and so on until 



250 LOCAL TREATMENT. 

we get one that will agree with the ease ; or else we must abandon 
all astringents, and fall back upon simple water. 

Temperature of Injections. — I know of no better rule to gov- 
ern the temperature of injections than the comfort of the patient. 
After a trial of tepid, warm, cool, and cold, let her suit herself 
by the effect they have upon her. Any temperature that is dis- 
agreeable should be avoided. The extract of opium makes a 
good anodyne injection. Five grains to a pint of tepid water, 
used for ten minutes, a quarter or half an hour, will often allay 
pain, arising from inflammation within the vagina, very readily : 
or one grain of extract of belladonna may be used in the same way. 
In fact, we may choose among the narcotic extracts, remember- 
ing that the solution must be impregnated with at least three 
doses of the medicine. Among the astringents, alum is the most 
common, the most useful and efficient astringent. It possesses 
the advantage of having no poisonous ingredient in it. As Dr. 
Bennett has taught us, it sometimes produces severe inflammation ; 
but this is doubtless owing to the inconsiderate use of it, and arises 
from its very efficacy in suppressing the vaginal secretion. One 
drachm to the quart of water, tepid, cold or warm, as the patient 
may desire, is perhaps the strength of solution that will most com- 
monly agree well ; but in this the patient should be governed by 
the sensation it leaves behind. There should at first be a sense 
of dryness, quite obvious to the patient, which should pass en- 
tirely off in less than six hours ; much better if it is entirely gone 
in two hours after the injection is administered. If this sense of 
dryness is perceptible, we should not allow the patient to use an 
injection for several hours after it is gone ; and the longer it con- 
tinues, the longer should be the intervals between them. If it 
last six hours, the interval should be twenty-four ; if two hours, 
the interval should be twelve ; if it last twelve hours, it should be 
discontinued, as it will most likely do harm. Another good 
astringent is sugar of lead ; this is, perhaps, next in efficiency to 
the alum. Double the quantity may be dissolved in the same 
amount of water. I do not like sulphate of zinc, although highly 
recommended. Thirty grains of it may be dissolved in a pint of 
water, as an astringent injection. The sugar of lead, or zinc, 
ought not to be continued as long as the alum. Some of the 
vegetable astringents are often used to good advantage, — strong 



LOCAL TREATMENT. 251 

decoctions of oak bark, rhatany, kino, or solutions of pure tannic 
acid. This last is an admirable astringent, not less efficient than 
the metallic, but also less injurious. It can be used of the same 
strength as alum, or even in double that strength, if desired. — In- 
jections and baths ought to be suspended during the time for men- 
struating ; if tepid and simple, they probably do no harm at this 
time ; but if cold or astringent, they are pretty sure to interrupt, 
more or less completely, this flow. During all the interval, they 
may -be employed uninterruptedly. — Almost every practitioner 
that has had much experience in the treatment of uterine diseases 
has a favorite injection. I am disposed to adhere to the simpler 
forms, seeking rather for correct principles by which to be gov- 
erned in administering them, than for great variety of substances. 
Accident in Injection. — There is one annoying, and sometimes 
to the patient alarming, little accident, that occasionally occurs 
during the reception of an injection in the vagina. Suddenly, 
while injecting the fluid, she is seized with severe cramping pain 
in the hypogastric region, which radiates to the back and hips, 
down the thighs, and sometimes over the whole abdomen. She be- 
comes sick at her stomach, is attacked with rigors, and her feet and 
hands often become cold. This pain continues, with exacerbations 
and remissions, for several minutes or hours, and when it subsides, 
leaves a sense of soreness, more or less considerable, correspond- 
ing with the severity of the attack. As the chilliness and rigors 
of the first few moments subside, there is reaction ; the patient 
becomes warm, and sometimes decidedly feverish. In all cases 
in which I have witnessed these symptoms, the patients were using 
a syringe, in the end of which, within the vagina, were several 
perforations, some on the side of the bulb at the end, and one at 
the very extremity. I think that one of the perforations had 
been accidentally placed in apposition with the external os uteri, 
and as the water was forced through this perforation, it entered 
the cavity of the cervix, and passed through it into the cavity of 
the body of the uterus, inducing the first shock, and the pains 
following it were caused by the spasmodic attempts on the part of 
the uterus to expel it. Although I have, in a large number of 
instances, been called upon to witness and prescribe for these 
symptoms, I have not seen them proceed to dangerous extremi- 
ties. I think these are cases of injection into the womb ; and in 



252 LOCAL TREATMENT. 

this respect, thej constitute my whole observation. An opiate 
injection per rectum, fomentations over the pubis, and quiet, are 
all the remedies I have found necessary. And often the symp- 
toms subside so soon that I have not been under the necessity of 
prescribing at all. — We occasionally meet with patients who can- 
not use baths or injections. In these cases it will be found, al- 
most invariably, that this inability arises from their producing 
an exaggerated effect. If it is simple tepid water used for the 
bath or injection, its results are too sedative. The bath debili- 
tates the patient, instead of simply soothing her. I have seen a 
single tepid bath prostrate a patient so that she would have to lie 
in bed for several hours before its effects wore off. A cold bath 
induces chilliness and permanent coldness, and reaction is not 
established : the system recovers from its effects only after a num- 
ber of hours, and that slowly. Hip, sitz, or general baths may 
produce these effects, and when they do so, should be abandoned 
as injurious. Other nervous symptoms, as difficulty of breathing, 
nausea, dysuria, &c, also occasionally seem to be the effects of 
baths. It is singular that some patients are so susceptible to the 
depressing effects of water that injections debilitate them very 
rapidly, and they are obliged to abandon them on this account. 
Cold water, as an injection, not unfrequently causes general cold- 
ness. But it is the medicated injections that most frequently pro- 
duce an exaggerated effect. Alum injections, even when the solu- 
tion is weak, with some patients produce such disagreeable and 
constant dryness, and sense of heat, as to make them quite intoler- 
able. And the sensitiveness of the vagina becomes so great that 
some patients are forced to cease the injections of alum wholly. 
The same objections apply to other astringents, to a less degree, 
and the consequence is, that however baths and injections may 
seem to be indicated, in the cases where idiosyncrasy renders them 
so objectionable, we must forego their use entirely. 

Should they be Used in Pregnancy ? — Is pregnancy an objec- 
tion to the use of local baths and injections ? I think not, with 
proper care; a hot bath about the hips would be objectionable; a 
very cold bath that might cause much of a shock, or internal con- 
gestions, would not be advisable ; but plenty of tepid water, and 
even cool water temperately used as baths, give the pregnant 
woman great comfort, and cannot generally be followed by any 






LOCAL TREATMENT. 253 

bad effect. Injections may be used with less caution than baths. 
The caution which we would administer to all is, that they should 
not be copious. In pregnancy the patient ought not to use more 
than a quart at one time. The injections should always be tepid 
or cool ; not very cold nor very warm, lest they stimulate the 
muscular, vascular, or nervous system of the uterus too much, and 
induce hemorrhage, or provoke contractions. Both of these 
effects, I think, I have known produced by such injections: the 
cold causing contraction and expulsion; and the very warm, hem- 
orrhage and death of the ovum. Strong astringents should also 
be avoided. Much comfort may be derived from anodyne injec- 
tions, when there is neuralgic suffering about the uterus or va- 
gina, during pregnancy. Cases of superficial inflammation, and 
even early ulceration of the vaginal portion of the cervix, may 
always be benefited by injections, baths, and the general treat- 
ment which I have heretofore detailed. In fact, most cases, if 
not all where there is no idiosyncratic objection to the baths and 
injections, will be very much benefited by them. When, however, 
the disease has been of long standing, or extends between the 
labia of the os uteri, or into the cavity of the cervix, these will 
only slightly benefit it. We must then seek for something that 
will more profoundly influence the nutritional changes, and the 
vascular and nervous tissues of the parts. 

Principles that should Govern us in Choosing the Kind of Local 
Treatment. — The substances I have been in the habit of using 
more frequently, and in fact, almost exclusively, are, after the 
various depletory measures, nitrate of silver, tannin, acid nitrate 
of mercury, nitric acid, and caustic potassa. Of these, the nitrate 
of silver is most frequently used. In fact, it has so generally 
answered the purpose in my hands, that I look upon the others as 
substitutes, and to be used only when it disagrees or fails. This, 
of course, refers to simple mucous inflammation, or ulceration. I 
shall, therefore, proceed to describe the use of nitrate of silver, as 
the standard treatment (if I may be allowed such a term) of inflam- 
mation and ulceration of the mucous membrane of the os and cer- 
vix uteri. Before doing so, however, I wish to draw a broad and 
well-defined line between cases to which these stimulants and caus- 
tics are applicable, and those to which local depletion and coun- 
ter irritation are adapted, as the local means best suited to them. 



254 LOCAL TREATMENT. 

And in order to be understood, I will again draw the attention of 
the reader to the fact, that when a mucous membrane is inflamed, 
touching it gives to the sense of the patient the idea of rawness ; 
when a part is touched in which the inflammation is beneath the 
mucous membrane, the idea of tenderness is experienced. When 
the mucous membrane of the cervix, for instance, is the exclusive 
seat of disease, if there is any disagreeable feeling experienced 
upon touching it, it is that of rawness ; but if the substance of the 
cervix or body of the uterus is inflamed, when it is touched by the 
finger, or an instrument, the patient complains of tenderness. We 
should bear in mind, too, in estimating the value of the sense of 
tenderness in distinguishing between mucous and submucous in- 
flammation, that we may sometimes be deceived by the complaints 
of patients, when the mucous membrane of the vagina is inflamed, 
into the opinion that inflammation is in the uterus. We ought, 
therefore, successively to press upon the different parts with our 
finger in a digital examination, and, after the speculum is intro- 
duced, with the probe, and question the patient, when each point 
is touched, as to the sensitiveness at that place. When pressing 
upon the uterus with the finger or probe, if the patient complains 
of tenderness or soreness, we ought to suspect submucous disease. 
Now, when the uterus is very slightly if at all tender to the touch, 
it is not likely that there is much submucous disease. To the 
mucous inflammation, these stimulants, astringents, and caustics 
are adapted, and to a more limited extent to the submucous. We 
very frequently find the increased secretion, the pus-colored mu- 
cus and rawness, combined with the deep tenderness and tense 
pain of submucous inflammation. In these cases we should be 
careful to subdue this last by depletory measures, alteratives, 
counter-irritants, &c, before we resort very freely to caustic and 
stimulant applications to the mucous membrane. When, however, 
there is evidence of inflammation of the mucous membrane of the 
cervix, outside or inside of the cavity of the body of the uterus 
only, a judicious employment of astringents and caustics will do 
more good for it than any other treatment with which I am ac- 
quainted. As this is the most numerous class of cases, and as 
separate submucous inflammation will come up for consideration 
after awhile, I will describe the treatment of it first, and the 
others afterward, premising that in mixed cases we should, to 






LOCAL TREATMENT. 255 

some extent, subdue submucous before we begin to use the treat- 
ment for the mucous inflammation ; and in such cases, when we 
do begin to treat the mucous membrane with the caustics, we 
should do so with caution, lest we increase the deeper, or submu- 
cous inflammation. I think this caution is not sufficiently under- 
stood, or acted upon. Too often the neck of the uterus is leeched, 
because it is inflamed, or it is touched with the nitrate of silver, 
because it is inflamed ; and yet if the practitioner were to stop 
and think a moment, he would readily decide that leeching will 
not cure mucous inflammation, or that nitrate of silver is not ap- 
plicable to submucous inflammation. 



CHAPTER XX. 

NITRATE OF SILVER AND ITS SUBSTITUTES. 

Chkonic inflammation is an habitual and established affection, 
having almost no tendency to spontaneous termination ; it must 
be subverted to be cured. This can unquestionably be best done 
by local means, when the part affected is accessible. Inflamma- 
tion of the cervix uteri is still less prone to spontaneous termina- 
tion, from circumstances already mentioned, viz., the menstrual 
congestions, determination of blood from its dependent position, 
and the excitement inseparable from the functions of the genital 
organs. On these accounts, the strong impression of nitrate of 
silver and its substitutes is required. There can be no doubt 
but that the stronger the impression we can produce, the more 
completely the chronic inflammation is swallowed up by the acute, 
and hence the more radical the change ; but if the impression is 
too strong, it may lead to greater damage than the disease for 
which it is used would produce. Doubtless, the white-hot iron 
which is recommended and used by some practitioners, causes 
more powerful effects upon the disease, more radically influences 
it than any application of nitrate of silver. But I think that we 
might not always be able to limit the extent of its influence within 
proper boundaries. The strong caustics are likewise more radi- 
cal than the milder, and cure inflammation of the cervix more 
rapidly, and with as much or even greater certainty ; but their 
effects are sometimes fearfully active, owing to an extension of 
the inflammation to other tissues than those to which they are ap- 
plied. In order to avoid all likelihood of bad results from such 
extension of inflammation, the milder caustics are used, and their 
lack of power is compensated by the repetition of their use. As 
already intimated, the nitrate of silver is by far the most effective 
of these, in cases of inflammation and ulceration of the mucous 
tissue of the cervix. When the inflammation extends to the 



NITRATE OF SILVER AND ITS SUBSTITUTES. 257 

deeper tissues it is not generally sufficient without the aid of other 
means. 

The nitrate of silver is objected to by some as. too strong and 
harsh a remedy to apply to so delicate an organ as the uterus, 
and speak of " burning the uterus" with lunar caustic as a "hor 
rible operation." Honest observation, however, will convince 
every practitioner of intelligence that, with the precautions ordi- 
narily enjoined, no more risk need be incurred by the use of ni- 
trate of silver than by the use of any other valuable remedy. 
That there are cases to which it is not applicable, and in which it 
is too harsh, is certainly true; and it will be my endeavor to point 
these out, and enable the practitioner, by attention to the matter, 
to avoid damage from the nitrate in almost all cases. It is best 
that we should be aware of the fact that the nitrate is not infalli- 
ble, nor always innocent ; but we should also lay aside the un- 
reasonable prejudice which arises from the term caustic, and which 
is hardly applicable to it, and determine, by our own observation, 
its title to the claim of a remedy in these cases. 

Preparation for the Use of Nitrate of Silver. — All the prepara- 
tion necessary, so far as the patient is concerned, will be effected 
in the examination for the purpose of clearly diagnosticating the 
disease, viz., the perfect exposition of the cervix uteri by the 
speculum, and the removal of all the mucus, blood, &c, by which 
it is often covered. This cleansing of the cervix from mucus, pus, 
or blood is important, from the consideration that these substances 
neutralize the effect of the nitrate by decomposing it. 

Should be Pure. — In selecting our remedy, we should endeavor 
to procure a perfectly pure article, free from adulterations and 
impurities, as they act as diluents of it, and render the applica- 
tion less effective. 

Forms of Application. — It may be applied in the solid or fluid 
form. The former I think, in the great majority of cases, prefer- 
able; while the latter, where the more concentrated solid form is 
too stimulant, may be made very useful. 

Solid Form best. — I am desirous of expressing a decided pref- 
erence for the solid form, because its application may be made 
more easily, certainly, and definitely, and because the peculiar 
impression of this substance is thus more surely produced. The 
solid should be in the form of cylindrical pieces of half an inch in 

17 



258 NITRATE OF SILVER AND ITS SUBSTITUTES. 

length ; the size and form usually found in the shops. In some 
cases, the larger will be found most convenient, while in others 
we will use more easily the very small pieces. 

Instruments for Using Nitrate. — I think a great deal depends 
upon the kind of instrument employed as a porte-caustique. In 
fact, we cannot expect to treat these patients successfully without 
having instruments that will expose the parts perfectly, and make 
the contact of our applications thorough and complete through- 
out. I am sure that many failures to cure arise from imperfec- 
tion of instruments and want of thoroughness in application. It 
has been my lot, frequently, to be called to see patients of this 
kind in consultation with medical men who had been treating them 
for months, with a glass cylinder for a speculum, and a goose- 
quill for a caustic-holder. In the very simplest of cases, where 
the inflammation or ulceration is all external to the os — an un- 
common thing — it is only possible, it is certainly not probable, 
that success can be secured by such imperfect means of operating. 
To say the least of it, such treatment is clownish. Let the prac- 
titioner have the best instruments, to completely include in its ex- 
posure the whole of the cervix and the vaginal cul-de-sac : and to 
enable him to apply his remedy to all the inflamed surface outside 
the os, and inside the cervix, and, if need be, up to the fundus 
inside the corpus uteri. If, upon trial, his instruments do not 
enable him thus intelligently and thoroughly to proceed, he will 
do his patient and his own reputation injustice, as well as will 
misrepresent his profession, and will be utterly inexcusable, if he 
does not invent, if need be, such means as will effect these objects. 
A porte-caustique for the solid nitrate, which I have used for sev- 
eral years, and with which I am very well satisfied, is made by 
Messrs. Tolle & Dagenhardt, instrument makers, in this city, and 
by Tieman, of New York. A large number of my medical friends 
have furnished themselves with this kind, believing it to be prefer- 
able to any of the common ones in use. The main feature is the 
flexible wire of which a portion of it is made. 

Flexible Oaustic-Jiolder. — This should consist of two pieces, one 
piece a sheath, about five or six inches long, and the other piece 
copper wire, about five inches long, surmounted at one end with 
platinum holders, into which the caustic may be fitted. These two 
pieces should be so made that when intended for use they can be 



NITRATE OP SILVER AND ITS SUBSTITUTES. 



259 



Fie:. 18. 



Fig. 19. 



f 



screwed together, making an instrument ten or eleven inches long ; 
when not used, the wire portion, 
holding the caustic, can be inserted 
into the sheath, thus making a 
caustic preserver as well as porte- 
caustique. We should be supplied 
with two or three sizes of these in- 
struments, as a matter of conveni- 
ence in cases where the os and 
cavity of the cervix differ in size. 
The object of having the stem made 
of copper or other flexible wire, is 
to enable us to bend it to suit the 
curvature of the uterus, or angle 
caused by a difference in the direc- 
tion of the axis of the vagina and 
uterus. In many cases, we cannot 
bring the cavity of the cervix and 
body of the uterus to correspond 
with the direction of the cavity of 
the vagina; in such instances, a 
straight, inflexible porte-caustique 
will but very imperfectly enter and 
penetrate beyond the os; but jf we 
have an instrument that will bend, 
and retain the flexure we produce 
in it, we may, as with the uterine 
sound, flex it so as to enter the 
cervix, and penetrate even to the 
fundus of the uterus. This flexi- 
ble caustic-holder, or some other instrument that will answer the 
purpose of entering the uterus, I consider indispensable to success 
in a large number of the cases we are called upon to treat. The 
part to which the application is to be made, should in all cases be 
divested of all mucus, pus, or secretion of any kind, before the 
medicine is placed in contact, and then it will act with more effi- 
ciency. 

Mode of Applying it. — The nitrate should be applied thoroughly. 
Where there is inflammation external to the os, the nitrate should 



The flexible caustic-holder, in two pieces, to 
he screwed together when used, and sheathed 
by placing the wire part in the other when 
not used. (Full size.) 



260 



NITRATE OF SILVER AND ITS SUBSTITUTES. 



be deliberately and gently passed over the whole inflamed or ulcer- 
ated part ; and should the disease extend inside of the os and cavity 
of the cervix, and even to the corpus uteri, it should be fearlessly 
but carefully carried up to the full extent of the disease. The con- 
tact should be perfect in every part, and sufficiently prolonged to 
produce all the effect it can produce by a single touch. If we use 
no more force than is necessary to keep the substance in contact 
with the part, there is no danger of keeping it there too long. 
This is the true "antiphlogistic touch," and it depends for this 
quality upon its completeness and thoroughness. Every time the 
application is made, we should try to be thus thorough in our use 
of it. 

Fig. 20. 




Showing the small-sized flexible caustic-holder as it is introduced into the cavity of the uterus for 
eudocervicitis and endometritis. 



Frequency of Application. — This kind of application can be 
profitably made, as an ordinary practice, about once in six days ; 
but we should be sure that all the perceptible influence of one 
application has subsided for at least twenty-four hours — and better 
if it is forty-eight hours — before another is made. This may re- 
quire, in some instances, eight, or even ten days ; or it may, in 
other cases, take place in five days. It is desirable, in making 
these applications, to avoid the period of menstrual excitement, 
by not making it two days before the time for it, and waiting as 
much as two days after its complete subsidence. In most pa- 



NITRATE OF SILVER AND ITS SUBSTITUTES. 261 

tients we will be able to make four applications a month ; but 
often only three can be tolerated. In common ulceration or mu- 
cous inflammation, external or internal to the os uteri, we may 
expect to be under the necessity of making twelve or fourteen 
applications of this sort. In many cases more applications will 
be necessary, and in a few cases a less number of applications 
will be required. Practitioners speak of curing their patients 
with three or four, some even with one application ; but I am 
sure that they are nearly always deceived. Out of the large 
number of patients I have treated for inflammation and ulceration 
of the cervix, I have never known one to be cured with less than 
nine or ten applications. To the inexperienced I wish to say em- 
phatically, be thorough in your applications, and be careful not 
to stop making them until every vestige of inflammation is gone. 

Thoroughness and Perseverance in its Use. — Failures occur very 
frequently on account of too little being done by the caustic. Im- 
provement is not a cure ; nor are we warranted in believing that 
a patient, because she is better, will continue to improve until she 
gets well. The treatment must be persevered in until the cure is 
complete. I have observed, also, that regularity is important in 
the treatment of these cases. It will not do to visit the patient 
at our convenience ; but we should see her and make the applica- 
tion at the regular time, and attend to it promptly. It is not 
unusual, I think, for physicians to see their patients with so much 
irregularity as to fail in procuring the benefit of each successive 
application, and, to some extent at least, lose the advantage of 
one application before another is made. As I have already pointed 
out, a large number of cases are attended with inflammation in the 
cavity of the cervix ; and in many instances, when there is no 
inflammation external to the os, the cavity of the cervix is the 
seat of much disease. We should remember this, and watch for 
it. I do not think it will be time wholly lost if I call attention* 
more particularly to the mode of using the nitrate in these cases. 
As I have before stated, the continued discharge of pus, muco- 
pus, or even mucus to a considerable extent, is evidence of endo- 
cervicitis, and we should not cease treating these cases until this 
discharge has completely ceased. An entire cessation of the 
discharge from the cervix should be verified by the use of the 
speculum. 



262 NITRATE OF SILVER AND ITS SUBSTITUTES. 

Application in the Cervical Cavity. — When the inflammation is 
in or extends to the cavity of the cervix, a flexible caustic-holder 
is indispensable to its successful treatment. We can be sure of 
making a thorough application inside the cervix — after exposing 
the neck in the speculum as fully and carefully as possible — by 
introducing the uterine sound into and through the cervix, in 
order to exactly measure the direction and amount of curvature, 
and then bending the wire of the porte-caustique so as to cor- 
respond with the curve of the sound which has passed into the 
uterus. After this preparation, if the caustic-holder is not too 
large, it will readily pass into the parts surveyed by the sound, 
and thus bring the nitrate in contact with the diseased surface 
very completely, which, if allowed to remain in contact for a few 
seconds, will produce its full effect upon it. 

Solution, Strength, and Mode of Using. — The nitrate of silver 
is applied also in solution, and very often a cure is effected by it 
in this way. To be efficacious, the aqueous solution of the nitrate 
should be very strong ; say one part of the silver to four parts of 
water. This solution is less powerful in its influence on the parts 
to which it is applied than the solid. 

Frequency of Using Solution. — It should be made consequently 
more frequently, every fourth day, for instance. Every part of 
the diseased membrane should be touched by it. We should not 
expect it to run upon the parts, but we should place it in contact 
by the instrument used. 

Acid Solution of the Nitrate of Silver. — Another solution of the 
nitrate may be made by dissolving it to saturation in pure nitric 
acid. This solution is, of course, very different to the other, and 
possesses the qualities of a powerful caustic. It must, therefore, 
be used with great caution, and subject to the rules for the govern- 
ment of the use of the acid nitrate of mercury, or other strong 
fluid caustics. 

Instruments for Using Solution. — The instruments I have used 
for applying medicines in fluid form to those parts, are the camel's- 
hair pencil, and a small swab, made by wrapping and fasten- 
ing with thread a little cotton to the end of a fine piece of flexible 
whalebone. Either of these instruments will pass into the os 
uteri, if necessary, and carry along with it the solution. They 
may, of course, be made to apply the fluid to the outside of the 



NITRATE OF SILVER AND ITS SUBSTITUTES. 263 

uterine mouth with equal efficiency. The watery solution may be 
used profusely, as there is but little danger from contact with the 
sound parts. The acid solution must, on the contrary, be used 
very sparingly. The treatment of ulceration with the aqueous 
solution of the nitrate will require a long time, comparatively, for 
a cure; certainly twenty applications will be almost always neces- 
sary. But we should not stop the use of it until the ulceration, 
congestion, and hypersecretion all disappear. 

Effects of the Solid. — When the nitrate of silver is applied in 
the solid form to an ulcerated or inflamed cervix uteri, the first 
effect is to coagulate the albuminous compounds on its surface 
into a thin, very white film of the thickness of white writing paper. 
This film adheres to and protects the surface from further influ- 
ences that are not sufficient to destroy it ; hence, after this effect, 
the nitrate can produce no more impression upon it. If, however, 
sufficient rudeness or force is used to separate this pellicle or film, 
from its adhesions, the nitrate will produce a similar effect upon 
the denuded surface, so that by forcibly passing the nitrate of 
silver over the mucous membrane for a number of times, a con- 
siderable amount of surface and substance, at some depth, may 
be destroyed. Taking these examples of its action, we see that 
it may be made to have a gentle or powerful caustic effect; hence 
the dispute as to whether it is or is not a caustic. If the nitrate 
is applied to the surface of a healthy mucous membrane, it pro- 
duces the same effects, but more slowly and to a less marked de- 
gree. The difference in rapidity with which this coagulum or 
film is produced on the surface of an ulcer has been seized upon 
by Dr. Bennett as diagnostic of ulceration. On the ulcerated 
surface it is almost immediate, while on the membrane retaining 
its integrity, the film is formed more slowly. The surface of an 
ulcer becomes immediately white, that of the membrane slowly so. 

Modus Operandi of Cure. — It has seemed to me that the appli- 
cation of the solid nitrate operates favorably, by two effects it 
has upon the diseased surface : the first is the profound stimulant 
action upon the capillaries, brought under its influence ; and sec- 
ondly, the formation of the film, which protects it from all foreign 
influence while it lasts. "When this film falls off, it leaves the sur- 
face of the ulcer raw and bleeding, or if it has been applied to the 
mucous membrane, it is deprived of its epithelium. This occurs 



264 NITRATE OF SILVER AND ITS SUBSTITUTES. 

about the end of the third day, sometimes sooner, and sometimes 
later. 

Discharge. — In the case of the ulcer, there is, after the loss of 
the film, quite a discharge of bloody serum, which lasts for forty- 
eight hours, or more. When this discharge ceases, it is on ac- 
count of the generation of a temporary or permanent epithelium. 
Now, if the ulcer is examined, its edges will be found more defined, 
while its general surface shows an improved state of the granula- 
tions. After each time the discharge becomes less, the diseased 
surface smaller, until a completely healthy appearance is assumed. 
The application usually produces some pain, which lasts ordinarily 
from three to twelve hours. For an application to be beneficial, 
the pain should not continue longer than twenty-four hours. 

Kind of Pain 'produced by Application. — The kind of pain pro- 
duced by the application is not always the same; in simple mucous 
inflammation, it is apt to be of a burning or smarting character, or 
it sometimes merely increases the pains felt before the nitrate was 
used ; the backache, pain in the side, or any other pain which had 
before existed, is increased, or, as the patient often expresses it, 
she feels the pain and other sensations which indicate the appear- 
ance of the menstrual discharge. In very many instances the 
patient complains of no additional suffering. If the inflammation 
extends to the submucous tissue, the pain is apt to be more severe; 
it is soreness, a tense pain, or throbbing pain, and does not sub- 
side as readily as when the inflammation is confined to the mucous 
membrane. 

Pain worse in Endocervicitis, — If the inflammation extends in- 
side the cervix, and the nitrate is introduced into its cavity, the 
pain is apt to be somewhat more severe. Although all the local 
troubles are generally increased for a few hours, we meet with a 
few patients who are immediately and very much relieved at the 
time of every application. This difference of suffering after each 
application is like what we observe with reference to the increase 
or decrease of symptoms after the beginning and continuance of 
local treatment. Some patients will suffer more after the com- 
mencement of local treatment for several weeks, and then gradu- 
ally improve, and get well, while others will go on to convalescence 
from the beginning. Others, again, will not improve until the local 
treatment is finished. In addition to the increase of local symp- 



NITRATE OF SILVER AND ITS SUBSTITUTES. 265 

toms under the application of nitrate of silver, patients are often 
rendered very much worse in their general symptoms. They are 
more nervous, their headache is increased, nausea is caused or in- 
creased; in fact, all the general symptoms enumerated as being 
caused by uterine inflammation will be found sometimes to arise 
from the effect of an application. 

On the other hand, very frequently the general symptoms may 
be, and are, permanently relieved by the local application from the 
beginning. If we observe through the speculum somewhat closely 
the effects of the application of the nitrate, we will find in the first 
place, and almost immediately, the ulcerated surface turn very 
white, from the formation of a film of coagulated albumen. A short 
time afterward, the mucous membrane of the vagina and neck of 
the uterus become livid from congestion. In two days, or less 
time, the albuminous pellicle begins to be detached, and the sur- 
face beneath is left of a scarlet red, and often blood may be seen 
exuding from this raw, uncovered surface. This exfoliation, or 
detachment, goes on for two days, until all the surface covered 
with the coagulum is left raw and bleeding ; on the fourth or fifth 
day, this surface is again covered with a very thin epithelium, and 
the membrane ceases to bleed. The injected condition of the 
uterus and vagina, with the finishing of these processes, subsides. 
In four, five, or six days, the effects are all gone, and the capil- 
laries begin to return to their old inactive state. Astringent in- 
jections do good by expediting all these processes, I think, par- 
ticularly the subsidence of congestion of the vagina. 

Chronic or Ultimate Effect of the Nitrate upon the Tissues. — The 
chronic effects of nitrate of silver — by which I mean the permanent 
influence it produces upon the tissues of the uterus — are worth 
closer ^tudy, and I should be glad to give them to some extent, 
but I propose at present, for want of time and space, to confine 
myself to a very limited view of them. 

Atrophy. — Sometimes the continued application of nitrate to the 
mucous membrane of the uterus induces condensation of the tissues 
beneath it, as well as in the mucous membrane itself; hence, re- 
sults, not unfrequently, true atrophy of that organ. 

Contraction of the Os. — In some cases, where the application 
is made to the os uteri for several months, that orifice becomes 
so small as to be of the size of a mere pin-hole. This may some- 



266 NITRATE OF SILVER AND ITS SUBSTITUTES. 

times take place while there is still inflammation in the cavity of 
the cervix. When this is the case, the secretions issuing from it 
will sufficiently indicate it. We need not be embarrassed in our 
treatment by this occurrence, as we can easily dilate the os uteri 
to almost any extent by tents of compressed sponge, or, if this is 
not at hand, slippery elm bark bougies. By using one of these 
tents, or bougies, for twenty-four hours before we desire to make 
the application, the opening will be large enough to answer all pur- 
poses. This contracted condition of the os uteri, where there has 
or has not been treatment, should not deceive us in reference to the 
presence of inflammation in the cervix. I have not unfrequently 
been called to see cases in which the mouth of the womb was 
scarcely perceptible to the eye on account of its contraction from 
inflammation or the use of the nitrate; several of which had been 
pronounced to be in an entirely healthy condition. Yet, from this 
minute opening, quite a large amount of muco-pus or tenacious 
mucus found its way in the twenty-four hours, and could be seen 
filling up the upper part of the vagina. By dilating the os uteri 
with sponge or slippery elm, and applying nitrate of silver inside 
the cervix for a number of times, all the distressing symptoms and 
the copious secretion subsided together. 

Effect upon Menstruation. — The menses are ordinarily rendered 
more easy and natural by the cure of the inflammation from the 
use of the nitrate applications ; but this is not always the case. 
At first, the sanguineous Aoav is increased ; this may be for the 
first, and even second month, but in some instances, after this; it 
then diminishes to a great extent, so as to amount almost to aine- 
norrhoea. I think this diminution of the menstrual flow keeps 
pace with and is dependent upon the condensing or atrophizing of 
the tissues of the organ. I have noticed this to occur so* often 
that I regard it as a sufficient indication for the withholding of 
this remedy altogether when this condition is observed. This atro- 
phizing and amenorrhizing influence of the nitrate is much more 
apparent after its introduction into the cervix and uterine cavity. 
I do not remember to have seen atrophy result from treatment 
with any of the substitutes for the nitrate. Sometimes the men- 
strual diminution results apparently from the effects of the fre- 
quent application of the nitrate to the mucous membrane of the 
cavity of the cervix and corpus uteri ; while, so far as we can 



NITRATE OF SILVER AND ITS SUBSTITUTES. 267 

judge from examination, there is no diminution in the size of the 
uterus, nor where it seems to be hardened in consistence. When 
this is the case, it is doubtless on account of the transforming in- 
fluence exerted upon the mucous membrane, perhaps a condensa- 
tion of its structure to such an extent as to prevent the capillary 
fractures which in health allow the transudation of the menstrual 
blood. 

Effect in Dysmenorrhea. — Painful menstruation is modified to 
a greater or less extent J)y the application of the nitrate. For 
the first, and even second month, there may not be much differ- 
ence, but after this the painfulness ordinarily diminishes until it 
ceases, or nearly so. Sometimes, however, at the first recurrence 
after the beginning of treatment, the pain is almost entirely re- 
lieved. This is remarkably the case in cases where the pain has 
been of a cramping instead of an aching or burning nature. 

How are we to knoio when to stop its use ? — How can we know 
when the nitrate has been sufficiently used? We are to continue 
the treatment, as I have before said, until every vestige of inflam- 
mation is removed. We must continue the applications until all 
the ulceration is removed that is within our sight, and then con- 
tinue them in the cavity of the cervix, and, if need be, the cavity 
of the body, until no free mucus is seen issuing from the cervix 
or in the vaginal cavity. It is a mistake to suppose that the 
inflammation is cured until the pus or mucus, or both, which are 
evidences of its existence, cease to appear when we make our 
examination. I cannot emphasize this direction sufficiently to do 
justice to its importance. While there is yellow or puriform mu- 
cus in any quantity issuing from the os uteri, there is ulcerated 
mucous membrane within the cavities above, which require the use 
of the applications ; while there is hypersecretion or free mucus 
issuing from the os uteri persistently, there is inflammation or per- 
sistent congestion of the mucous membrane of the cavity of the 
cervix, which requires the lunar caustic for its cure. We should 
continue it, therefore, until these cease to flow, as well as until 
the obvious ulceration is healed. 

The Nitrate sometimes fails. — The nitrate sometimes fails to 
cure these inflammations and ulcerations, and although it may not 
be considered necessary by the reader to inquire into the causes 
of its failure, yet I think we will treat these cases more success- 



268 NITRATE OF SILVER AND ITS SUBSTITUTES. 

fully by rightly understanding why we do not succeed by the use 
of the ordinary remedies. 

Not strong enough. — There are cases in which it falls short of 
producing the impression necessary to arouse the capillaries to a 
more healthy action ; it is not sufficiently powerful. In these cases 
no apparent or real good is done, but the inflammation continues 
about the same all the time. The cases in which it fails in this 
way are generally indolent ; the granulations are large and flabby, 
the cervix large and doughy to the touch, with very little sensi- 
bility, and the surface is inclined to bleed easily. 

Substitute in such Cases. — These require some of the stronger 
substitutes, applied occasionally, and alternated with the nitrate, 
or with some of the milder substitutes. The caustic potassa is 
much the best substitute in such cases. My plan of applying it, 
in such cases, is to moisten a verv small camel's-hair brush with 
the mucus of the vagina, and rub it over the stick of caustic 
potash until the brush becomes well saturated with it. I then 
apply the brush to the diseased part. I continue to apply the 
mucous solution of the potash to the surface in this way until the 
desired effect is produced. In this manner we may procure a 
strong stimulant influence, or slight caustic effect, without the de- 
structive substances running upon the sound parts. A swab, 
made by tying a small piece of cotton to a small stick of whale- 
bone, will answer the purpose equally well. We first moisten the 
cotton swab in the thick mucus, and pass over it the stick of 
caustic until it dissolves off and retains a part of it, and then 
apply it to the diseased part. Or we may dip the brush or swab 
in strong nitric acid, and apply to the parts. The swab I think 
the better of the two, as it does not take up the caustic fluid so 
freely, and hence is not likely to allow it to flow over the sound 
parts. 

Sometimes the Nitrate fails without apparent Reasons. — But 
we often meet with instances in which, without any apparent rea- 
son, the nitrate fails to do any good. These cases we should 
study, with a view to ascertain whether the impression is not suf- 
ficiently powerful, or whether the impression is not of the right 
sort, and select our substitute according to our conclusions in this 
respect. 

May cease to do Good after being Beneficial. — Again, the nitrate 



NITRATE OF SILVER AND ITS SUBSTITUTES. 269 

may do good and seem to be curing a case, but after several ap- 
plications there seems to be no advance. The ulceration remains 
the same from week to week, without any change. It will be 
necessary, in these cases, almost invariably to resort to some 
stronger stimulant, as the acid nitrate of mercury, the acid nitrate 
of silver, or the caustic potash, with the brush or swab. 

Acid Nitrate of Mercury, and of Silver. — The acid nitrate of 
mercury can be procured at the shops ; the acid nitrate of silver 
is made by dissolving the nitrate of silver in the strongest nitric 
acid, to saturation. Any of these may be tried once a month, to 
be succeeded by milder substitutes, as tannin, sul. cupri, creasote, 
&c, at intervals of a week between them. 

Sometimes the Nitrate of Silver does Harm. — But sometimes 
the nitrate of silver not only fails, but it entirely disagrees with 
the cases, and it has to be abandoned. I have known a number 
of cases in which the nitrate aggravated the inflammation every 
time it was applied. 

In Aged Persons. — This is particularly apt to be the case in 
old persons, after the childbearing age has passed. In them the 
inflammation assumes, nearly always, a peculiar appearance ; the 
cervix is small, the granulations minute, the surface very red, and 
the discharge a thin and acrid muco-pus. These are apt to be ob- 
stinate, and almost invariably made much worse by the applica- 
tion of the nitrate, and, what seems singular, are benefited by the 
stronger stimulus of potassa fusa. One application of caustic pot- 
ash, with the brush or swab, every four weeks, followed every six 
days with tannin, usually answers very well for this kind of ulcer- 
ation. Creasote generally agrees well with it. 

Aphthous Inflammation. — Another sort of inflammation, at- 
tended with patches of exudation not unlike aphthae, is almost in- 
variably very much aggravated by the application of the nitrate 
of silver. This requires milder treatment. Tannin and creasote, 
alternated every six days, with one application, if necessary, of 
caustic potassa, will answer very well. On several occasions, I 
have found the nitrate, after having done well for several weeks, 
suddenly and unaccountably to disagree with cases, and the ulcera- 
tion spread rapidly. These have been rendered tractable by the 
caustic potash, pretty freely applied. 

Causes too much Discharge. — But without reference to the kind 



270 NITRATE OF SILVER AND ITS SUBSTITUTES. 

of ulceration, the nitrate of silver, so far as I am able to judge, 
sometimes disagrees and does harm, en account of the excessive 
discharge or hemorrhage it causes. Ordinarily, when the nitrate 
is thoroughly applied, as I have elsewhere said, there is some dis- 
charge of bloody serum, amounting to half an ounce, or double 
that quantity. This takes place from the second to the fourth 
days inclusive. Sometimes it is much less, sometimes it is more 
abundant. I have met with instances, however, where there was 
great hemorrhage, and was so exhausting as to preclude the use 
of the nitrate entirely. So far as I can see, there is no peculiar 
appearance by which we might be led to suspect the occurrence 
of hemorrhage, before trying the remedy. One case that I am 
now treating, is peculiarly susceptible in this respect. A single 
application of nitrate of silver, in the middle of her menstrual 
month, caused her to flow so copiously as to make it necessary to 
keep her bed, use cold applications, and acid drinks. In spite of 
these, she lost fifteen or twenty ounces of blood in eight or ten 
days. This was repeated the next month, and it became neces- 
sary to abandon the remedy altogether. 

This, of course, is a remarkable case, but in many instances so 
much loss of blood has taken place as to cause me entirely to 
forego its use in those cases. In the cases in which hemorrhage 
forbids the use of the nitrate, the substitutes I have found most 
suitable are the caustic potassa and tannin. The caustic potassa 
may be used once in the middle of each menstrual month, with the 
little cotton swab I have described, so as thoroughly to stimulate 
the inflamed part and produce very little cauterization ; and every 
fourth or fifth day in the intervals, completely saturate the in- 
flamed surface with pulverized tannin, applied with the camel's- 
hair pencil or the swab. Before using the tannin, we should en- 
tirely remove the viscid mucus in the neck and about it. We need 
not be apprehensive of any severe effect from the tannin, either 
in the cavity of the cervix, or on its external surface ; we should 
apply it fully and freely to the whole inflamed surface. Creasote, 
alternated with the tannin every fourth or fifth day, often suits 
such cases. When the ulceration is external and extensive, in 
these bleeding cases, it is best generally to apply the caustic pot- 
ash in the solid form, so as to produce a more profound effect. 

Nitrate sometimes causes too great Pain. — Too great pain is 



NITRATE OF SILVER AND ITS SUBSTITUTES. 271 

sometimes the result of application of nitrate of silver. The pain, 
after application of the nitrate, may be merely slight, the patient 
scarcely feeling any inconvenience whatever ; or, what is usual, it 
may produce some pain and suffering in from six to twenty-four 
hours, and then subside ; or, in rare, exceptional cases, cause in- 
tense pain. 

The pain, when severe, may subside in a few hours, and is not 
worth making any change in the remedies, or the pain may be 
severe and protracted. When this last is the case, injurious in- 
stead of beneficial effects are the result, and we should seek for a 
substitute. Caustic potash, tannin, creasote, acid nitrate of mer- 
cury, or some other acknowledged substitute, should be employed. 
The acid nitrate of mercury is an excellent substitute in such cases, 
alternated with the tannin, &c. 

Worse in Cases of Submucous Inflammation. — This local pain, 
after using the nitrate, is more common where there is some sub- 
mucous inflammation ; a few leeches will frequently remove the 
disposition entirely. 

Without these local pains, or other suffering with them, there 
is, as the result of the application of the nitrate to the os and cer- 
vix uteri, sometimes excessive nervous symptoms. The nervous 
excitement sometimes becomes so great that it is very alarming. 
A patient upon whom I attended but a few months since, was ren- 
dered entirely sleepless, and almost insane, by the exciting influ- 
ence of these applications, and it was necessary to send her off to 
the country for tranquillity and recuperation. In quite a number 
of instances which have come under my observation, the nervous 
symptoms were so increased, that I had to change the treatment, 
or use substitutes that would not produce these peculiar effects. 
It is singular, that these very nervous patients complain very 
little, if at all, of the local effects of the application, and are only 
rendered nervous by it. 

I should hardly finish what I ought to say of the nitrate of sil- 
ver, and its substitutes, were I not to state that the latter do not 
cause any of these symptoms of distress which I have mentioned 
as the occasional result of the application of the former. There 
is something, then, peculiar and distinctive in the influence of the 
nitrate of silver, as evidenced by this fact. It is not merely 
stimulant, astringent, or caustic, in its effects upon this inflamma- 



272 NITRATE OF SILVER AND ITS SUBSTITUTES. 

tion, but it has its own peculiar influence. It may be asked, if 
the nitrate causes these bad effects sometimes, and none of its sub- 
stitutes ever do, why use the nitrate at all ? 

In the first place, when it does agree with a case, there is no 
remedy that acts so kindly, so efficiently and certainly, as this. 
In the second place, the weaker substitutes are slower and less 
certain than the nitrate, and consequently, when successful, take 
more time to make a cure. And in the third place, the stronger 
caustics, as the acid nitrate of mercury, the acid nitrate of silver, 
and the caustic potash, require greater care, and any accident oc- 
curring from them may be much more serious, and, if carelessly 
or awkwardly used, are likely to do damage to parts not intended 
to be influenced by them. The nitrate requires almost no prep- 
aration or precautionary measures for its use ; for the stronger 
substitutes we must prepare carefully, and use much precaution- 
ary vigilance. The nitrate in solution does not produce such de- 
cided effects as the solid, and hence, of course, will not cause hem- 
orrhage, pain, or nervousness to the same extent that the latter 
does. Can we continue to use the nitrate when it causes the above 
inconveniences, and counteract or neutralize its effects by some 
other remedy ? The pain and hemorrhage are apt to become less 
at each successive application, and hence, if the patient can bear 
them for a few times, we may continue to employ them, and then 
the cases are generally cured by them ; but occasionally they dis- 
agree after having acted kindly for a time. 

Remedy for the Hemorrhage.— -When the hemorrhage is con- 
siderable, Dr. Bennett recommends a plan which I have followed 
with good results sometimes, and that is, to make the application 
to only a part of the ulcerated or inflamed surface. When the 
application is extended inside the cavity of the cervix, this direc- 
tion cannot be observed. And it is in these cases that the hemor- 
rhage is the worst. Astringent injections and cold applications, 
baths, &c, when the hemorrhage is not very great, will afford some 
relief and enable us to go on in their use. Generally, however, 
we will have to do" with the substitutes when the hemorrhage is 
considerable. 

Remedies for the Pain. — When the pain is great, emollient in- 
jections of linseed infusion, infusion of slippery elm bark, with 
laudanum, in large quantities, thrown into the vagina, or half a 



NITRATE OF SILVER AXD ITS SUBSTITUTES. 273 

teaspoonful of laudanum in a little starch-water or linseed tea, 
per rectum, will also aid very much in quieting. It is better in 
all cases for the patient to remain still in the recumbent position, 
for some hours after an application; when there is much pain, it is 
indispensable. The patient should be quiet until the pain is over. 

Remedies for Nervousness. — When the nervous symptoms are 
excessive, we should be cautious about repeating the applications. 
If opium does not disagree with patients, its anodyne influence 
may enable us to continue the treatment. Tinct. hyoscyamus and 
camphor may also be tried, or valerian, brandy, &c. But some of 
these, particularly the last, must be used sparingly. If the ner- 
vousness subsides in a few hours, either with or without the aid of 
the anodynes, we can still resort to the nitrate applications. But 
if it continue at all obstinate, we must use some of the substitutes. 
I can but remark again, that it is singular that the caustic potash, 
and all the stronger caustics, produce less pain, less hemorrhage, 
and less nervous excitement, than the nitrate of silver. 

Is its Application allowable in Pregnancy? — Is it ever allow- 
able to apply the nitrate to the cervix uteri, inside or out, after 
the commencement of pregnancy ? I confess that I am afraid to 
do so, and if a patient becomes pregnant during treatment, I ad- 
vise a discontinuance until after confinement, and complete invo- 
lution has taken place; say three months after accouchement. I 
know that Drs. Bennett and Whitehead both advise the use of the 
nitrate during the first three months, for the purpose of avoiding 
abortion, but the great irritation it sometimes causes intimidates 
me from using it, or recommending others to do so. I think I 
have seen abortion caused by it, in cases where pregnancy was not 
suspected. On the other hand, I have seen cases where preg- 
nancy was not thought to exist, treated for some time without any 
bad effects. Upon the whole, I think it is much the best practice 
to desist after conception, or not to begin if we know it has taken 
place. 

Loss of a Piece in the Cervix. — Some object to the introduction 
of the nitrate of silver, in the solid form,' into the cervix uteri, lest 
a piece of it accidentally be left in that cavity, and very bad re- 
sults follow. I have had this accident to occur to me repeatedly, 
and as yet I have not seen any bad results from it. It is true, the 
pain is sometimes a little more severe and protracted in duration, 

18 



274 NITRATE OF SILVER AND ITS SUBSTITUTES. 

but it dissolves and runs out, or is expelled into the vagina, which 
is the more probable course, and there is dissolved and neutralized 
by the mucus of that cavity. I have been so strongly impressed 
with the harmlessness of the presence of a small piece of the ni- 
trate there, that I have, in certain cases, intentionally passed some 
up the cervix, and allowed it to dissolve in the fluid and distribute 
itself over the surface of that cavity. 

Pressure by Bougies in JEndo cervicitis. — Before leaving this 
part of the subject, I will mention another substitute for the ni- 
trate, which, in certain cases, I have seen do a great deal of good; 
that is, pressure upon the mucous membrane of the cavity of the 
cervix, by means of bougies, prepared sponge, &c. In some cases, 
with all the facilities afforded by flexible caustic-holders, our ap- 
plications are imperfect, and the cure is unreasonably protracted. 
This may be the case when the cavity of the cervix is small, or 
tortuous from flexion or inflammatory adhesions. A bougie of slip- 
pery elm, large enough to fill the cervical cavity, introduced as 
high as the inflammation extends, and allowed to remain for 
twenty-four or thirty-six hours, not only prepares the way for 
other applications, but favorably modifies the disease by its pres- 
sure upon the capillaries. In order to use this bougie handily, we 
may cut it about two inches long and about the right size, and 
then tie a piece of thread around one end, so that it can be re- 
moved at will. After exposing the cervix with the speculum, we 
may, with the dressing forceps, introduce it as high as possible, 
leaving the end with the ligature extending out of the os uteri. 
If not supported it may slip out, and not remain long enough 
to do any good ; hence it is a good plan to place a sponge or 
piece of cotton against it, to prevent it from being discharged. 
This should be repeated every four or five days. The use of the 
stem pessary proves beneficial, too, I think, in some instances, on 
account of the stem pressing upon the inflamed part inside the 
cavity of the cervix, and thus changing the character of capillary 
action. If used intermittingly, it will act better in this respect 
than if allowed to remain constantly in place. We may use flexi- 
ble gum bougies, wax or metallic. The object to be gained, it 
should be borne in mind, is pressure, intermitted and sufficiently 
strong to produce a decided impression. I think I have, on several 
occasions, verified the excellent effect of pressure applied in this 



NITRATE OF SILVER AND ITS SUBSTITUTES. 275 

way, when it was difficult to make perfect applications of the ni- 
trate ; the main point of the disease being so high up, and the 
canal at a pretty sharp angle with the axis of the vagina. 

Medicated Bougies. — These slippery elm bougies may be made 
to carry medicated applications, and retain them in contact with 
the inflamed spot, when situated high up in the cervix. Calomel 
may be placed, as I have done, upon the end of the bougie, or 
ointment of creasote, calamine ointment, ointment of lead, or any 
other that is likely to produce a proper stimulus. The tincture of 
iodine, the iodine ointment, and also the iodide of potassium, in 
pieces, pushed before the bougie, to be dissolved and diffused over 
the mucous membrane, are good substitutes for the nitrate, that 
may be used with the bougie. The use of bougies in this way is 
like the treatment sometimes instituted for inflammation in other 
mucous canals, as the urethra, for instance, with salutary effect. 
The danger from the bougie is less, perhaps, than any irritating 
application to the part, producing its effect, not by causing acute 
inflammation, as does the nitrate and other strong stimulants, but 
by pressing upon the part, and thus diminishing the capillary cir- 
culation in it, reducing the inflammation. 

I subjoin a summary of the treatment of Robert Ellis, Esq., 
Obstetric Surgeon to the Chelsea and Belgrave Dispensary, Lon- 
don Lancet for July, 1862, reprint. It is a choice tabular view of 
the kinds of ulceration we meet with, and the very best mode of 
treating them, and I think will be useful to the inexperienced : 

VARIETY. TREATMENT. 

1. Indolent Ulcer. — Cervix hypertro- For a few times the caustic pencil, — 
phied, of a pale pink color, and hard, solid nitrate silver. Afterwards, the 
Os patulous to a small extent. Ulcer solution of nitrate of silver in strong 
of a rose red. Granulations large, nitric acid. 

flat, insensitive, and edge of the ulcer 
sharply defined. Discharge : mucus, 
with a little pus, and occasionally a 
drop of blood. 

2. Inflamed Ulcer. — Cervix tender, Occasional leeching,hip bath (warm), 
hard, a little hypertrophied, hot and emollient injections. Then acid nitrate 
red. Vagina hot and tender. Ulcer of mercury several times, succeeded by 
of a vivid red. Granulations small and the solid lunar caustic, potassa fusa, or 
bleeding. A livid red border around cum calce. 

the ulcer. Discharge : a muco-pus, 
yellow and viscid, with frequently a 
drop of bright red blood entangled 
in it. 



276 



NITRATE OF SILVER AND ITS SUBSTITUTES. 



VARIETY. 

3. Fungous Ulcer. — Cervix soft, large, 
spongy to the touch. Os wide open, so 
as to admit the finger. Ulcer large, 
pale, studded with large and friable 
granulations. Discharge : glairy, 
brownish mucus, frequently deeply 
tinged with blood. 

4. Senile Ulcer. — Cervix small, red, 
a little hard. Ulcer small, extremely 
sensitive, of a bright red color. Gran- 
ulations very small, red, and irritable. 
Discharge : a thin muco-pus. 

5. Diphtheritic Ulcer. — Cervix of or- 
dinary size, a little hot, dry, and ten- 
der. Ulcer covered in patches with a 
white membrane, adhering closely, ir- 
ritable, and readily bleeding beneath. 
Discharge: a thin acrid mucus, with- 
out pus, but occasionally tinged with 
blood. 



TREATMENT. 



At first the caustic pencil. Subse- 
quently, nitric acid, solution of nitrate 
of silver, or acid nitrate of mercury ; 
electric, or actual cautery. 



Potassa fusa, or strong nitric acid, 
with nitrate of silver once or twice at 
long intervals. Then solid sulphate of 
copper, in pencil. 

At first, electric cautery, potassa cum 
calce, or acid nitrate of mercury, two 
or three times at long intervals. No 
nitrate of silver. Subsequently stimu- 
lant applications, tincture of iodine or 
sulphate of copper. 



CHAPTER XXL 

TBEATMEXT OF SUBMUCOUS INFLAMMATION. 

Submucous inflammation, as has been seen, is observed under a 
variety of accompanying circumstances ; with mucous inflamma- 
tion, without mucous inflammation, and without change of size or 
consistency, and with fibrinous deposit, enlargement, and indura- 
tion of the cervix. Of course, all these circumstances will more 
or less modify the treatment of the different cases in which they 
are observed to occur. 

Submucous Inflammation , tvith Ulceration and Mucous Inflam- 
mation. — There is often evidence of submucous inflammation when 
ulceration affects the mucous surface of the cervix. When the ten- 
derness is not considerable, nor the part enlarged and tumefied, the 
cure of the mucous disease by the means heretofore indicated will 
suffice to cure the submucous also, and hence the case will need no 
further treatment whatever. But if the cervix is quite tender 
to the touch, somewhat swollen and hot, and the ulcerated surface 
red and excavated, and giving out pus copiously, other remedies 
than those adapted for the cure of the mucous inflammation ought 
to be used. Leeches, in numbers to suit the intensity of the in- 
flammation and the general condition of the patient, should be ap- 
plied, and repeated every week, until the tenderness and heat have 
subsided to a great extent. But as local depletion will not always 
produce the effect, it will almost always be better to resort to in- 
ternal alteratives and sedatives. Very many of these cases yield 
promptly to the alterative influence of mercury, gradually induced, 
with an occasional active cathartic of salines. Probably the best 
general plan is to leech the cervix, give a cathartic of calomel, to 
be rendered a little more active by sulph. magnesia, citrate of mag- 
nesia, Seidlitz powders, or Congress water. If, after two or three 
days, the local tenderness, pain, and heat continue, it will be well 
to give a grain of protiodide of mercury, or calomel, in similar 
doses, combined with opium, every four or six hours until slight 



278 TREATMENT OF SUBMUCOUS INFLAMMATION. 

ptyalism is produced. The cathartic, depletory, and alterative 
treatment should be continued until the submucous portion of the 
disease is removed ; when the inflammation of the mucous membrane 
may be treated as I have directed when particularly speaking of 
that subject. As leeches are not always attainable, it becomes a 
matter of interest to find a substitute for them. We have this, 
fortunately, in scarifications; a remedy to which we may resort 
without apprehension when local depletion seems to be indicated. 

Scarification — Mode of doing.- — The mode of doing this is prac- 
tised differently by different individuals. The plan which I have 
found most convenient and effective, is to make the incisions in the 
os uteri, and direct them somewhat outward. A knife with a 
probe point is best adapted for this operation. The blade should 
be about two inches long, and one-eighth of an inch wide, very thin, 
and mounted upon a light straight handle, seven or eight inches 
long. After the neck and mouth of the uterus is brought full into 
view by the speculum, the probe point may be introduced half an 
inch through the os into the cavity of the cervix; when thus 
placed, the handle should be carried as far to the side of the specu- 
lum to which the edge is directed as allowable, and then withdrawn 
with enough pressure to make the edge cut through the mucous 
membrane. This will allow of a considerable flow of blood. If 
we wish to obtain a large amount of blood, several of these little 
incisions may be made around the circle of the os. The copious- 
ness of the flow may be regulated by the depth as well as number 
of these incisions. In a few days ordinarily all trace of these 
little wounds is lost, and the os resumes its usual appearance. 
This is the class of cases to which the depletion so often directed 
is very well adapted. The indication for the depletion is in the 
tenderness, heat, and swelling, all of which are dependent upon 
submucous inflammation, and not upon the ulceration, or other 
signs of mucous inflammation. Depletion has, indeed, but little if 
any good effect upon inflammation of the mucous membrane. 

Leeching. — Although it may seem hardly necessary to give any 
direction with regard to the mode of applying leeches to the cervix, 
it may be useful to the young practitioner in the treatment of 
these cases to do so. A common glass speculum, introduced so as 
to include and isolate the cervix, is what I have been in the habit 
of .using. The leeches are thrown down to the bottom of the 



TREATMENT OF SUBMUCOUS INFLAMMATION. 279 

speculum after the parts are cleaned of mucus, and the leeches are 
watched until they seize the part. Three are about as many as 
can conveniently be used in the speculum at one time. If more 
are considered necessary, they must be applied after the bleeding 
from the bites of the first has pretty well subsided. The bleeding 
usually continues for several hours, and as much or more blood 
is lost after they are removed as they draw. Submucous in- 
flammation sometimes outlasts the mucous, and when we have 
this last cured, the troublesome symptoms still continue, or very 
seldom the submucous begins and continues independent of the 
mucous part of the disease. These cases, unattended by hyper- 
trophy or induration, as they sometimes are, cannot be diagnosti- 
cated by the speculum alone. The physician is rather surprised, 
perhaps, that the symptoms of uterine inflammation should continue 
after an examination with the speculum shows a perfectly healthy 
color, size, and secretion of the organ ; yet this is sometimes the 
case. If the sound or finger be pressed against the parts, they 
will be found to be tender. This condition is not unfrequently 
left after the cure of chronic mucous inflammation, and keeps 
up the symptoms. When it is a sequel to the chronic mixed 
form of mucous and submucous inflammation, it is apt to sub- 
side spontaneously after a time. When it exists independent of 
mucous inflammation, and is not the sequel to the mixed form, it 
is* often, though I think not necessarily, connected with scanty 
menstruation. Not unfrequently in this variety of the disease, 
the uterus is smaller than natural. It is quite common, when at- 
tended with scanty menstruation, to attribute it to this last cir- 
cumstance ; but I am inclined to think the deficient menstruation 
and atrophy are both attributable to the inflammation as a cause. 
It would be irrational to stimulate the uterus to greater conges- 
tion, to increase the flow when it was thus the subject of inflam- 
mation. The treatment should be directed to the inflammation. 
The remedies used will depend upon the acuteness of the symp- 
toms : if the pain is considerable, or the tenderness great, leech- 
ing moderately or cupping upon the sacrum is quite desirable, but 
it should be used only to remove the tenderness and pain ; the sub- 
sequent treatment should consist in the use of alteratives, counter- 
irritants, and tonics. Small doses of mercury, followed by the sa- 
line purgatives, as alteratives, answer admirably ; six grains of 



280 TREATMENT OF SUBMUCOUS INFLAMMATION. 

blue mass every fourth or fifth night, followed in the morning with 
Epsom salts, Seidlitz powders, or citrate magnesia, is a good alter- 
ative. One grain of calomel may be substituted for the blue mass, 
if the patient is plethoric. If the patient is anaemic or weak, the 
bleeding should not be resorted to, but the alterative may be ac- 
companied with tonic treatment. The preparations of iron, syrup 
of the iodide, syrup pyro-phosphate, iron by hydrogen, or the 
tincture, are good and eligible tonics. I am very partial to the 
chl. tinct., given in twenty-drop doses three times a day. , I have 
seen a great deal of good done by it in removing that congestive 
sort of inflammation that so often keeps up the sensitiveness of 
the organs, after the more active symptoms had been removed, or 
in anaemic and weak patients. When there is not much acute- 
ness of inflammation, or necessity for depletion, much good will 
result from proper counter-irritation. 

Seton as a Counter-irritant. — The seton is one of the best means 
for this purpose. It should be introduced and allowed to remain 
for several months, and caused to discharge pretty freely for the 
most of that time by occasional turning, and if necessary, impreg- 
nation with some irritating powder, as cantharides, or savin root. 
It should be made of one whole, large skein of silk, or even larger, 
so that the impression may be powerful. The best place for it is 
over the symphysis pubis, or in cases where one of the iliac regions 
is the seat of pain, this is a desirable locality. I have sometimes 
directed my patients to dress the seton daily with mercurial oint- 
ment, until gentle mercurialization occurred, with much resulting 
benefit, I have thought. Soothing injections often diminish the 
sensitiveness of the uterus ; and if they do no other good, should 
be used for this purpose. Two teaspoonfuls of laudanum to a pint 
of water, to which thirty grains of acet. plumbi are added, make a 
very good injection. This should be passed into and through the 
vagina for several minutes. Belladonna, hyoscyamus, aconite, 
gelseminum, and cicuta, may be used also with the same view, in 
proper quantities. 

Hardness and ^Enlargement — Treatment of. — After the inflam- 
mation in the substance of the cervix has continued for a great 
length of time, fibrinous deposit hardens the tissue, and makes an 
enlargement which becomes permanent and difficult of cure. This 
enlargement and hardness are attended with various degrees of 



TREATMENT OF SUBMUCOUS INFLAMMATION. 281 

tenderness ; sometimes the parts are not very sensitive to the 
touch, while in other cases the least touch causes exquisite pain 
and suffering. These conditions of course will very much modify 
the treatment. When there is tenderness, heat, and other signs 
of an acute condition of inflammation, leeching or cupping, cathar- 
tics, alteratives, anodynes, should be resorted to, until these symp- 
toms are removed or very much relieved. I have seen a slight 
ptyalism do away with these symptoms very quickly, and induce 
such a state of comparative comfort, that the patients believed 
themselves cured. Where the increase in size is considerable, 
however, they will soon return, and it is necessary to apply reme- 
dies that will cause a deeper and more lasting influence. 

Caustic Potash — Object in Using. — The only one to which I 
have ever resorted for this purpose is the caustic potash ; and 
when judiciously used, I think it will fulfil the indications quite 
completely. The object, as stated by Dr. Bennett, is not to de- 
stroy the part, so much as to induce a change in the action of its 
vessels that will cause an absorption of the fibrinous deposit upon 
which the enlargement depends. I would have the reader to ob- 
serve that this is the kind of case to which the powerful action of 
the caustic is applicable, viz., when there are tenderness and other 
symptoms indicating a continuance of inflammation. 

Mode of Applying. — Too great caution cannot be taken in ap- 
plying this caustic, for fear of an unnecessary, if not mischievous 
extension of its effects to other parts. We should be prepared 
with the ordinary quadrivalve speculum, a pair of dressing for- 
ceps, some cotton-wool, acidulated water, and sweet oil. The 
parts ought to be fully exposed, the whole cervix included in the 
end of the speculum, and illuminated with a good light from a 
large window, and the patient so placed that we may operate with- 
out restraint of any kind. When the cervix is thus included in 
the speculum, we should take a piece of cotton-wool, as large as 
may seem to be necessary, thoroughly saturated with acidulated 
water, and place it beneath the cervix, so as to underlie the part 
contained within the speculum, and come in contact with the end 
of the cervix below the point to which we wish to apply the caus- 
tic. We should also pour into the speculum a small quantity of 
the acidulated water, enough to fill up the end of the instrument 
as far as it can be without being in contact with the part to be 



282 TREATMENT OF SUBMUCOUS INFLAMMATION. 

operated upon. It is almost if not quite impossible to apply the 
caustic potassa without haying it to run more or less. This should 
be remembered and be provided for. Some liquid, as here recom- 
mended, that will immediately decompose this chemical, should 
be kept in contact with all the parts where there is a possibility 
of its touching by flowing upon them. I have sometimes, where 
the direction of the speculum allowed the retention of the fluid, 
simply poured in the acidulated water until all the parts were 
inundated that were in danger of injury from the contact of the 
remedy. After having taken these precautionary measures to se- 
cure the surrounding parts from harm, we may secure the caustic 
in any way most convenient, and apply it as may seem necessary 
in the case. Ordinarily I seize it with my dressing forceps, and 
use them for a caustic-holder. The extent and duration of the 
application must be determined by the appearances at the time 
of using it. The enlargement and induration sometimes include 
the whole extremity of the cervix, while at others it is wholly or 
nearly confined to one of the lips of it. I do not think it desira- 
ble to apply the caustic extensively. One slough is usually suffi- 
cient, and most beneficial, for our application. This should be 
made in the centre of the indurated part, if the induration be con- 
fined to one of the cervical labia ; but if the whole extremity is 
the subject of the induration, the slough may be made in the cen- 
tral portion of the cervical lip, at the upper part of the included 
portion. The depth of the slough should be sufficient to destroy 
the mucous membrane and penetrate the submucous tissue, say to 
the depth of an eighth of an inch or more. This may be done by 
holding the caustic steadily in contact with the part sufficiently 
long. The slough should be not larger than a dime in circumfer- 
ence, and, in cases of moderate enlargement, the size of a half 
dime will answer all purposes. With reference to the depth of 
the impression, I would say that I have oftener regretted having 
made too light an application, than too prolonged. Thorough- 
ness, combined with carefulness, is just as necessary in the appli- 
cation of the caustic potassa, as of the nitrate of silver. One ap- 
plication is not ordinarily sufficient ; but it should not be repeated 
too near together, The best rule by which to be guided as to the 
time for repetitions, is to wait until the effect of the first has en- 
tirely subsided. This will require from three to six weeks, owing 



TREATMENT OF SUBMUCOUS INFLAMMATION. 283 

to the extent of slough and the curative capacity of the individual. 
As soon as the effects of the first application have entirely sub- 
sided, we may make a second application, as remote from the lo- 
cality of the first as the size of the induration will admit. When 
this has gone through the different phases of inflammation, slough- 
ing, and healing, we may make the third, &c. We may thus 
repeat the applications until the induration is removed. The 
time selected for making these severe caustic applications should 
also have reference to the general condition of the patient, and 
the special condition of the uterus. It would of course be im- 
proper to make the application at a time when the patient was in 
any way predisposed to febrile or inflammatory action, or preg- 
nancy ; menstrual congestion should also forbid it. Midway be- 
tween the menstrual periods the uterus will most likely be in the 
best condition. The patient should remain in bed for the first 
twenty-four hours after this sort of application, and she should 
abstain from fatiguing use of the lower extremities for at least a 
week. If there should be much pain, heat, or febrile excitement, 
which, in my observation, are very rare accompaniments, sooth- 
ing injections, of flaxseed infusion with laudanum, may be repeat- 
ed three or four times in twenty-four hours, injections of tinct. 
opii in the rectum, fomentations to the hypogastrium and peri- 
neum, and warm hip baths. In all cases, where no particular 
objection exists, the patient should use the sitz baths, and injec- 
tions of tepid water, twice a day, between the applications. As 
soon as the slough is completely detached, and suppuration indi- 
cates a good condition of the ulcerated surface, the danger some- 
times attending these applications is no longer to be apprehended. 
I have not found it necessary, nor do I think it best, as directed 
by Dr. Bennett, to dress the place with nitrate of silver applica- 
tions. The dangers above alluded to, so far as I am aware, are 
inflammation in the cellular tissue by the side of the uterus, and 
an increase of the submucous inflammation in the substance of the 
uterus. These may almost always be avoided by the precaution- 
ary after-treatment I have directed. Such acute inflammations 
of this kind as I have seen, have seemed to me to be always pro- 
duced by careless exposure to cold, or incautious exercise of the 
legs within two or three days after the application. They are apt 
to supervene after the lapse of five or six days, or after the surface 



284 TREATMENT OF SUBMUCOUS INFLAMMATION. 

of the inflamed part begins to produce healthy pus. If severe 
cellulitis should occur, we should have no hesitation in promptly 
treating it with energetic means. The evils will thereby be di- 
minished, if not prevented. One leeching over the sacrum, or the 
groin of the side most painful, would, if early resorted to, do much 
toward resolving the inflammation. It should be followed by ca- 
thartics, calomel and opium, fomentations, counter-irritants, &c. 
We must of course be governed by the acuteness of the attack in 
the selection of our remedies. After the complete subsidence of 
the inflammation, there may still be enlargement of the cervix. 
Should this be treated with caustic, with a view to its reduction ? 
I think not. It is attended by very little, if any inconvenience. 
We will meet, however, with very few instances in which the 
inflammation wholly subsides while there is enlargement. The 
latter seems to keep up the former ; at any rate, they are usually 
together. 

In all these cases of chronic submucous inflammation, we will 
expedite the cure by maintaining the functions in the most healthy, 
or nearest to a normal condition, within our power. The bowels 
should be regulated particularly; they should be free and unloaded. 
I have never found it necessary to resort to the actual cautery for 
the cure of these indurated and enlarged cervices. The caustic 
potassa has been sufficiently powerful for all purposes. Perse- 
verance should be a guiding principle. Twelve months is not a 
long time to effect a cure when this kind of organic lesion results 
from inflammation. 



CHAPTER XXII. 

HYPERTROPHY OF THE CEEVIX. 

Hypertrophy of the Cervix is different from enlargement caused 
by fibrinous accumulation, and consists of an increase in the proper 
tissues of the organ. It is a real hypertrophy. Although not 
nearly so frequent as the enlargement from chronic inflamma- 
tion, it is not of very rare occurrence. The symptoms do not differ 
from prolapse of the uterus sufficiently to characterize it. The 
patient generally experiences a sense of bearing down or weight 
on the perineum, pain in the sacral region, leucorrhcea, sometimes 
menorrhagia, and the various sympathetic symptoms already suf- 
ficiently dwelt upon of uterine irritation. 

Diagnosis. — Upon examination the cervix is found enlarged. 
There are three general forms observed so well marked as to en- 
title them to special mention. The first is such as we usually find 
in the nulliparous, an elongation of the whole cervix, and some, but 
not generally, very great circumferential increase of size and with- 
out much deviation from shape. This form is seen in Fig. 21. 
The next variety is an elongation and enlargement of the anterior 
or posterior labium as represented in Fig. 22. I am not certain 
from my own observation whether this is always a pure hyper- 
trophy or a mixture of this process with fibrinous infiltration, 
probably the latter. 

The last variety is an elongation of the two labia, and a devia. 
tion from their natural direction, as seen in Fig. 23. The anterior 
projects forward and sometimes shows itself through the vaginal 
orifice immediately beneath the urethra. The projection was so 
great in one instance I met with as to be constantly exposed to 
the air and friction of the clothing, and thus become hard and 
ulcerated. 

The only appropriate treatment is amputation, and it is generally 
sufficient to remove all the disagreeable symptoms resulting from it. 



286 



HYPERTROPHY OF THE CERVIX. 



The plan I have usually pursued in removing this growth is by 
ecrassement. The chain of the ecraseur is passed around, at the 



Fig. 21. 



Pig. 22. 





Fig. 23. 




Figures showing three varieties of hypertrophic elongation and enlargement of the cervix 
uteri. The dotted lines show the proper place for amputation. 

place where the point marked out by the dotted line is seen in 
the figures, and the rachet slowly worked until the division is com- 



HYPERTROPHY OF THE CERVIX. 287 

plete. This operation is easily performed, and is perfectly safe 
when carefully done, and the parts cicatrize in a few days. An 
inconvenience mentioned by Dr. J. Marion Sims, is encountered in 
some instances in amputating the first variety, viz., the contrac- 
tion of opening of the cervical cavity. It is an inconvenience, 
however, that is of no great importance generally, and may be 
remedied by making a small incision with a blunt-pointed bistoury 
immediately after the operation of amputation. Dr. Sims ampu- 
tates the cervix with scissors. He exposes the organ with his 
speculum, cuts the parts squarely through at th'e dotted lines, and 
then draws the mucous membrane together over the cut surfaces 
with silver sutures. This lessens the size of the cut surfaces and 
the parts heal more readily. 



CHAPTER XXIII. //" 

PEKIMETEITIS. 

There is an abundance of areolar tissue in the pelvis ; it is be- 
tween the bladder and pubis, the bladder and vagina, the vagina 
and rectum, but in greater amount between the sides of the vagina, 
uterus, and bladder, and the pelvic bones. In a loose manner it 
fills up the space indicated, and is covered by and included in the 
folds of the lateral or broad ligaments of the uterus. Within 
these folds of the peritoneum, the ovaria, the Fallopian tubes, and 
the round ligament, are included with the cellular tissue. Inflam- 
mation attacks this areolar tissue, not unfrequentlj on one side, 
and involves the tube, the ovary, ligament, and peritoneal cover- 
ing ; less frequently both sides are simultaneously inflamed, and 
still less often that part between some of the hollow organs of the 
pelvis is affected, when we have a comparatively small point of 
disease, as, for instance, between the bladder and vagina, or this 
last and the rectum. This is perimetritis. There is a strong ten- 
dency when inflammation is lighted up in any part, to spread to 
the space at the side of the uterus and vagina covered by the 
broad ligament, on one or both sides. The inflammation is apt to 
run its course rapidly, as is usual in areolar tissue, either to reso- 
lution or suppuration, and as this tissue is abundant, and the or- 
gans in the pelvis easily moved, the effusive products are likely to 
be copious. In the first stage of inflammation, serum is rapidly 
poured out between the folds of the peritoneum by the side of the 
uterus and vagina ; it pushes these organs to one side of the pel- 
vis, and forms a prominent inflammatory tumefaction at the side 
of the pelvic cavity, within easy reach of the finger. This tumid- 
ity becomes harder in a short time, and forms a solid medium of 
connection between the uterus and wall of the pelvis, indicating 
the change from serous to fibrinous effusion. Within a week or ten 
days, in very acute cases, in others from two to four, or even six 
weeks, the areolar tissue is broken down into copious suppuration. 



PERIMETRITIS. 289 

In some instances, the inflammation does not advance beyond the 
stage of serous effusion. When, after lasting for an uncertain 
time, the symptoms begin to subside, the tumefaction disappears, 
and the patient soon recovers her health ; while in others it is ar- 
rested after fibrinous infiltration has cemented the parts solidly to- 
gether. Although the symptoms are moderated from their first 
acuteness when this is the case, some of them, as undue sensitive- 
ness, soreness, and sense of weight, and other kinds of pelvic dis- 
tress, remain for a considerable time, and the patient recovers from 
the attack very slowly, if ever completely. "When suppuration 
takes place, if it is completely and readily evacuated, the patient 
very soon regains her health and strength. In some patients of 
broken-down or damaged constitutions, sloughing and extensive ul- 
ceration increase the damage to the organs. I once saw a syphilitic 
patient in whom extensive and rapidly spreading ulceration opened 
the rectum, vagina, bladder, and, finally, the peritoneal cavity. 
Suppuration in this case was unhealthy and ichorous, smelling 
strongly, and produced excoriation of the parts over which it flowed. 
If the evacuation of the pus is imperfect on account of opening into 
the rectum or bladder, and even in the vagina, the symptoms may 
be prolonged for months and even years. And in some cases where 
the evacuation of the pus and subsidence of the inflammation seemed 
complete, the disease recurs usually with diminished acuteness a 
number of times. I once had a patient in whom an attack of peri- 
metritis was contemporaneous with incipient pregnancy for four dif- 
ferent times while under my care. In each one of these four times, 
the inflammation commenced at about the time the menstrual flow 
ought to have appeared after conception. Every time there was 
copious suppuration, a free discharge of the pus, and, to all ap- 
pearance, a complete recovery from the inflammation. The inter- 
vals were about two years in duration. I have seen three in- 
stances in which the recurrence of the inflammation had occurred 
at irregular intervals from three months to a year for over six 
years, another ten, and one as much as eighteen years. In 
this last case, the abscess was situated at the left side of the 
uterus, and usually after a week or ten days of acute suffering, 
it discharged about a half ounce of fetid pus, and then disap- 
peared, so that nothing but a slight induration at the point men- 
tioned indicated any tendency to its recurrence. This chronic 

19 



290 PERIMETRITIS. 

form, I think, is not very uncommon. I believe, also, that chronic 
induration in the spaces occupied by the pelvic areolar tissue, 
caused by fibrinous infiltration, not unfrequently presents itself as 
the effect of acute perimetritis, producing many distressing symp- 
toms, and rendering the patient liable to a recurrence of acute at- 
tacks. The extent of the inflammation and tumefaction is governed 
somewhat by the condition of the patient. If she be in the puer- 
peral state, the inflammatory excitement is likely to be greater, 
the swelling more extensive, and the suffering more severe, than if 
this condition is not present. Pregnancy increases the intensity 
of the disease beyond what it is in the unimpregnated condition ; 
the fever will run higher, and the extent of the inflammation be 
greater. The same will be the case after abortions. The mildest 
form of perimetritis is that which occurs in the unimpregnated 
female. 

Judging from my own cases, I should think that three-fourths 
of these attacks terminate in suppuration ; and we may reasonably 
apprehend such a result as the rule. When pus is formed, it finds 
its way out through several different channels. First, and most fre- 
quently, through the vagina ; the wall of the abscess nearest the 
vagina ulcerates through into this canal, and the pus escapes first 
in small quantities, and finally freely, until the whole is evacuated; 
a number of days and even weeks may elapse before the discharge 
ceases, and the cavity is filled up. The escape through the vagina 
is not only the most common, but this is the most favorable outlet, 
as the opening is generally pretty free and permanent. Second 
in frequency as the medium of discharge is the rectum ; the pus 
makes its way into this intestine generally at the upper end of the 
septum between it and the vagina. The discharge is compara- 
tively slow and unsatisfactory, appearing with the stools in small 
quantities, and continuing for a length of time. The opening into 
the bowels is almost, if not invariably, valvular and tortuous, per- 
mitting the escape with difficulty. If there does not occur a sec- 
ond opening into the vagina, the abscess will generate pus almost 
as fast as discharged, and we may expect times of partial relief 
and exacerbation for months and even years. I am acquainted 
with an instance in which the patient has not been entirely free 
from suffering from this cause for the last six years, and a number 
of times has been prostrated for weeks. But few days pass with- 



PERIMETRITIS. 291 

out the patient observing matter in fecal evacuations. The pus 
makes its way at other times through the inguinal regions ; some- 
times it points in one of the labia, or burrows through the gluteal 
region. It also perforates the uterus or bladder, and follows the 
channels leading from them outwardly. I have not seen an in- 
stance in which the uterus was penetrated. When the pus finds 
its wav into anv of these holllow organs, it causes severe irritation 
in them, and efforts at expulsion. Dysuria, dysentery, and vagi- 
nitis, are generally caused by it to a moderate degree, but some- 
times the suffering from this cause in these organs is very great. 
But another mode of escape from the cavity of the abscess is into 
the peritoneal sac. This is comparatively infrequent, fortunately, 
but invariably fatal. I believe no instance is on record to contra- 
dict this statement. I have been unfortunate enough to be con- 
nected with two cases in which this untoward circumstance occurred. 

One of the patients was attacked in the puerperal state, and 
after suffering for eight weeks with the inflammation of the tissues 
around the uterus, acute general peritonitis terminated her life in 
about thirty-six hours from the time it commenced. Upon exam- 
ining the abdominal cavity, an opening was found near the left 
sacro-iliac junction, which communicated with the interior of the 
abscess, and several ounces of pus was in the cavity of the peri- 
toneum, that had made its way through this opening. The usual 
lesions of extensive and acute peritonitis gave evidence of the 
cause of death. The other case was in a sterile married woman, 
about twenty-five years of age, who had been treated three weeks 
for typhoid fever. Dissection revealed a large pelvic abscess, with 
recent rupture into the peritoneal cavity, and extensive peritoneal 
lesions. This overwhelming peritoneal inflammation lasted only 
about eighteen hours before the death of the patient. When the 
peritoneal symptom supervened, it was regarded as the result of 
the intestinal ulceration which sometimes so suddenly terminates 
typhoid fever. 

Causes. — As before intimated perimetritis occurs as a sequel to 
abortions, and labor at full term, and there is but little doubt but 
that these two conditions sometimes predispose to the disease. 
The menstrual congestion seems to do the same thing. Any cir- 
cumstance that fills the pelvis with blood in active congestion may 
so predispose to it. Cold suddenly applied to the surface or to 



292 PERIMETRITIS. 

the feet and legs may excite the already congested parts into a 
state of inflammation. Much exercise of the limbs in walking or 
standing on them for a long time, when the pelvic vessels are 
already distended and excited, has, on some occasions, seemed to 
me to awaken inflammation. The incautious use of strong caustics 
to the cervix uteri may give rise to it. I think I saw a case in 
which perimetritis was brought about by severe exercise in walking 
immediately after the use of caustic potassa. Excessive venereal 
indulgence, doubtless, predisposes to this inflammation, if it does 
not produce it alone. * 

Symptoms. — The patient is attacked suddenly, usually with pain 
in the pelvis, hypogastrium, or iliac regions, which rafliates to the 
sacrum, loins, and abdomen. Sometimes it passes down one ex- 
tremity, or there is pain in both legs. The pain, generally at first 
aching and moderate, may become very severe, and darting or 
cramping in character. In the beginning, or after the inflamma- 
tion has lasted a little while, there is pain or difficulty in urinating, 
and the passage of faeces through the rectum is painful, also, by 
pressing upon the inflamed parts. The patient usually experiences 
a sense of weight about the perineum, and dragging in the loins 
and hips. All the pains are much aggravated by motion, or as- 
suming and continuing in the erect posture. Pressure over the 
epigastric and inguinal portions of the abdomen increases the pain 
and suffering. 

At the commencement of the pain the patient is attacked with 
rigors of greater or less severity. The chilliness may be slight, 
but often it amounts to severe shaking and trembling ; reaction 
proportionate to the intensity of the chill succeeds ; the head aches, 
the limbs are pained, the skin is hot and dry, and the tongue coated, 
dry, and parched, as is also the mouth. These symptoms may 
come on very suddenly, and the case be well marked in a few hours 
from the time they commence, or so moderately and gradually as 
to be several days in assuming prominence. In puerperal patients 
they occur generally several days after confinement, and seem to 
be induced by undue exertion or exposure. In such cases the 
symptoms are likely to be more intense than in the non-puerperal 
cases. The pulse is rapid, the nervous system much disturbed, the 
heat great, and often there is delirium. The high febrile excite- 
ment is attended with severe pain, extending in various directions. 



PERIMETRITIS. 293 

There are some instances of non-puerperal cases where the symp- 
toms are quite intense, but as a general rule they are less so than 
in the former. Tumefaction and tenderness over the lower parts 
of the abdomen indicate a local peritoneal inflammation in many 
of the more severe instances, although this is not always the case. 
Some of these puerperal cases so closely resemble cases of metro- 
peritonitis^-if they are not so indeed — that the cases are regarded 
as attacks of puerperal fever. So intense are the symptoms in 
some instances as apparently to jeopardize the life of the patient 
immediately by the gravity of the general pelvic and abdominal 
inflammation. And when the tumefaction and tenderness of the 
abdomen subside, the febrile reaction is moderated or becomes 
more paroxysmal, we find a hard tumor generally on one side dip- 
ping down into the pelvis and extending sometimes to the ribs and 
across to the umbilicus ; or it may be developed in the mesial por- 
tion of the abdomen and pelvis, extending upward to a greater or 
less degree. Tumors of this kind are tender, and may be detected 
in the pelvis by a vaginal examination. They do not always sup- 
purate, but occasionally disappear by absorption. At other times 
they produce copious quantities of pus. This inflammation some- 
times dissects up the peritoneum, over the osseous, iliac, and lumbar 
muscles, to a great extent dissolving out the areolar tissue in a 
large space. The distension and tenderness are quite frequently 
confined to one side, showing the point of greatest intensity of the 
disease, or the side to which it may be confined, but we often find 
them extending entirely across, and sometimes considerably up the 
abdomen. These symptoms appertain to the first stage, and last 
for from four or five days to two weeks, and in rare cases longer, 
when they are gradually succeeded by those that indicate the sup- 
purative stage. The pain becomes less acute, and changes ordi- 
narily to a burning character, quite as distressing, if not more so 
than at first. It is worse at night, and prevents the patient from 
resting. The fever assumes something of a remitting type. It is 
more intense in the evening and night ; toward morning a moisture 
is observed upon the skin, the heat becomes less, and there is some 
amelioration in the suffering. After a little longer, and the 
paroxysms are very marked, chilliness in the after part of the day 
is succeeded by a very rapid pulse and intense heat of the surface. 
This fever lasts for six or eight hours, and is resolved by a copious 



294 PERIMETRITIS. 

perspiration. These perspirations are accompanied with great 
languor and depression. The patient is debilitated and much worn 
by the continuance of these symptoms. At length, after days of 
this exhausting suppurative fever, the pus makes its way through 
the walls of the abscess, and is discharged through some of the 
outlets mentioned above. If the evacuation is free, and the dis- 
charge considerable, the relief is very great indeed, the fever sub- 
sides, the perspiration ceases, the spirits are good, the appetite 
becomes excellent, in fact the change in the patient is very great 
and gratifying. Convalescence is now established, and in a few 
days all the serious and distressing symptoms have vanished. If 
this discharge is not free, and but a small quantity of the matter 
escapes, although there is relief, it is not so complete. The patient 
is temporarily better, but not convalescent. The opening is not suf- 
ficient, the pus continues to increase and imperfectly discharge, 
and fluctuations in the intensity of suffering continue to inspire 
hope and cause depression, until a freer opening occurs in the 
same place, or another one allows the pus to escape more freely. 

This description is intended to apply to cases of considerable 
intensity in the puerperal or non-puerperaLpatient. But the de- 
grees of intensity are very different in different instances. Some- 
times the symptoms are so slight as to scarcely attract attention, 
until the discharge begins to make its appearance. At other times 
there is distressing fever, but the local symptoms are so poorly 
marked that the case is misapprehended. I have known the fever 
to last for three or four weeks, ending in hectic, with its exhaust- 
ing accompaniments, before the true nature of the case was dis- 
covered. Two cases of this kind were treated for typhoid fever, 
which they certainly very much resembled, until, upon examina- 
tion, the collection of pus was discovered. These inflammations 
are more frequent than is generally supposed, and often over- 
looked. An inflammatory fever, followed by hectic symptoms, 
should cause us earnestly to search for the location of the inflam- 
mation. 

An example of the occasional insidiousness of this affection is 
exhibited in the following case : 

Mrs. A , aged twenty-four, married two months, has suf- 
fered for the last four years with moderate dysmenorrhea, and 
occasional leucorrhoea. Sexual intercourse has given her much 



PERIMETRITIS. 295 

pain from the first since her marriage ; after three weeks the pain 
in the coitus became intolerable. At this time she had severe pain 
in the back and pelvic region constantly, but not so severe as to 
prevent her being about in the attention to domestic duties and 
taking a short trip by rail with her husband. She had some very 
slight pelvic reaction, with sense of chilling, for about twenty 
days, when the paroxysms assumed something of a hectic character, 
lasting from three o'clock until seven or eight, p.m., terminating 
with copious diaphoresis. A little later a very severe pain in the 
hypogastric region was developed, attended with frequent efforts 
at urination. In about four days from the prevention of this pain 
she began to pass pus in large quantities in the urine, together 
with marked quantities of blood. Upon making examination at 
this time the pelvis on the right side and front portion was filled 
by a hardness very tender to the touch, which had crowded the 
uterus back upon the rectum and down so that the os was in con- 
tact with the perineum. These symptoms and the examination 
fully declared it a case of perimetritis. 

When the disease becomes chronic, the symptoms become ob- 
scure, and the cases so completely resemble uterine disease, that 
nothing but a careful physical examination will enable us to arrive 
at positive conclusions. In the chronic form there are exacerba- 
tions and remissions, and during the remissions the sufferings are 
not very considerable. When the paroxysms occur at the men- 
strual periods they sometimes pass for dysmenorrhoea, which they 
very much resemble. Sometimes, in the chronic form, the suffer- 
ing during the paroxysm is severe and prostrating, while at others 
it is only sufficiently intense to be inconvenient. 

Diagnosis. — Although the symptoms, in most cases, are severe 
and sufficiently prominent, they are not often distinctive. Several 
other affections resemble it in many symptoms. Hence, the only 
way to arrive at correct diagnosis is by physical examinations. 
The finger will be the only instrument necessary. It is cruel to 
use the speculum, while it affords us no aid in the vast majority of 
cases. I should not think it necessary to caution the reader 
against the use of this instrument if I had not seen it resorted to 
more than once to the great torture of the patient. In making 
examinations for this kind of case, the patient should be so placed 
that we may use both hands if necessary. When one or two fingers 



296 PERIMETRITIS. 

are introduced into the vagina, they will detect unusual tumidity 
in the pelvis. Sometimes this tumidity extends to the bottom of 
the pelvis on one side, and occasionally apparently fills up the 
whole lower part of the pelvic cavity ; at other times the tumidity 
is circumscribed and confined to one side high up, behind the 
uterus, or before it. The tumefied parts are generally hard, quite 
so, and very tender to the touch, so that a small amount of pres- 
sure causes great suffering ; the uterine neck is almost always 
pushed out of its place to one side, forward or backward, upward 
or sometimes downward ; the vagina is generally hot and dry, and 
all the parts sensitive. If we place one hand above the pelvis 
while the fingers of the other are in the vagina, we will have a con- 
sciousness of a tumor between the fingers of the two hands. It is 
not always the case that any tumidity may be felt above the supe- 
rior strait, but generally there is tumefaction in one iliac region, 
or sometimes in both. The tumefaction may extend much above 
these regions, high up into the abdominal cavity, though I think 
not often. If the tumefaction is considerable, the uterus is firmly 
fixed in its place, but when less, this is not the case. In child- 
bed patients we may distinguish perimetritis from peritonitis 
by digital examination per vaginam. There is not the hard tume- 
faction in the pelvis in the last as in the first. Tenderness and 
general distension of the abdomen are greater in peritonitis ; the 
pulse is more rapid and is peculiar. These may and probably are 
often combined in puerperal fever, when the diagnosis is of less 
importance than when they are separate affections. The perito- 
neal inflammation supervenes after delivery much earlier — gen- 
erally on the second day — than any of the localized inflammations 
do. Perimetritis is more likely to attack the patient when or after 
she begins to make exertion, or is exposed to cold several days, 
six to ten, and even more after delivery. 

From acute metritis in the puerperal or non-puerperal state, it 
may be distinguished by examination with the finger. There is 
not much difference in the mode of attack and history between 
acute metritis and perimetritis ; but by a careful tender survey of 
the pelvic organs, we may separate the inflamed from the sound 
parts. In metritis the uterus is generally and symmetrically en- 
larged, and extends lower down in the pelvis, and if touched at 
any point is tender ; in perimetritis this organ is not enlarged, and 



PERIMETRITIS. 297 

if touched anywhere in such manner as not to press it against or 
move it on the side where the inflammation exists, is not the sub- 
ject of painful impressions. The tenderness in perimetritis is 
generally to one side of the uterus, close to the walls of the pelvis. 
If the inflammation lie in the bladder, we may easily ascertain 
this fact, by pressing this organ between the fingers in the vagina 
and those above the symphysis pubis. From metatithmenia it is 
distinguishable by the tenderness and firmness of the tumor, the 
febrile symptoms, and the history of the two conditions : perime- 
tritis being previously inflammatory, while metatithmenia, when 
inflammatory at all, is so some time after the commencement of 
the symptoms. The bloody tumor may be handled without much 
pain, is soft and yielding, and commences at the time of menstru- 
ating with sharp pain likened often to severe colic, without chill 
and fever at the beginning ; sometimes with collapse more or less 
intense. Carcinoma filling up the lateral parts of the pelvis, is 
sometimes mistaken for perimetritis, but more often the latter is 
mistaken for the former. Carcinoma is insidious in its incipiency. 
It has made great advance almost always before symptoms indi- 
cate its existence, while perimetritis is heralded by inflammatory 
symptoms from the start. The hardness of carcinoma is greater, 
the tumidity more irregular and devoid of tenderness ; it is not 
hot as in inflammation. The discharge from carcinoma is cadaver- 
ous in odor, — in the advanced stage, — thin and ichorous in char- 
acter. In perimetritis the discharge is pus, and if it smells at 
all, the odor is faintly fecal. I have noticed this last feature in 
several instances of perimetritis, when the evacuation of the pus 
was free and copious through the vagina. 

The diagnosis from chronic metritis is not always easy. When 
perimetritis is chronic, it causes many of the symptoms which we 
observe to be present in chronic metritis. It will require a care- 
ful consideration of the symptoms and history of the case, and 
physical examination. 

Chronic perimetritis ordinarily results from an acute attack, 
that was accompanied with a discharge of pus more or less co- 
pious, and paroxysms of less intensity have succeeded, growing- 
more mild, until the symptoms become obscure. Paroxysmal dis- 
charge of pus is one of the constant symptoms of chronic peri- 
metritis. Upon a thorough and careful examination of the pelvic 



298 PERIMETRITIS. 

cavity, we may find some small spot, not in contact with the uterus, 
but by the side of it ordinarily, that is hard and tender to the 
touch. In chronic metritis there is not always tenderness. 

Prognosis. — This is generally favorable. There is probably 
more danger in attacks during the puerperal condition, or after 
miscarriage, than in unimpregnated patients, although the very 
large majority of these cases terminate favorably. Of course, I 
leave out of this consideration such instances as are attended by 
peritonitis of simultaneous origin, and constitute only a part of the 
whole puerperal fever. I do not think there is much difference in 
the fatality of uncomplicated cases occurring under these diverse 
circumstances. When perimetritis proves fatal, it is generally in 
one of three ways. 1st. By exhaustion caused by excessive and 
long-continued febrile excitement, symptomatic of extensive inflam- 
mation. 2d. The exhausting effects of hectic fever, diarrhoea, 
diaphoresis, and want of nourishment. 3d. Severe complications, 
arising during the progress, as peritonitis, by extension of inflam- 
mation ; or the more rapidly fatal form of peritonitis, caused by 
effusion of pus in its cavity. I have seen three fatal cases. Two 
of them resulted from rupture of the abscess, and discharge of the 
pus in the peritoneal cavity. One of these was puerperal, and 
death occurred ten weeks after confinement ; the other non-puer- 
peral, and ended in eight weeks from the attack. The one which 
proved fatal from exhausting hectic without evacuation of the pus, 
terminated in sixty days from the commencement. 

A great many cases terminate in the chronic form. The cause 
of this sort of termination is almost invariably incomplete evacua- 
tion of the pus, and, as a consequence, imperfect obliteration of 
the cavity of the abscess. The pus accumulates from time to time, 
and fresh eruptions, attended with a greater or less exacerbation 
of the symptoms, every few weeks or months, occur as this result. 
Or the external opening, wherever it may be, does not close, and 
there is a constant discharge of greater or less quantity, keeping 
up a kind of fistulous canal, leading generally some distance to the 
main seat of the difficulty. Or in still another sort of cases, the 
pus seems to be entirely evacuated, and the cavity obliterated, and 
there is nothing left but a small point of indurated tissue, which 
is the nucleus of inflammatory action under certain circumstances, 



PERIMETRITIS. 299 

as pregnancy, unusual excitement of the sexual organs, from other 
reasons, &c. 

Treatment. — Notwithstanding the strong and rapid tendency to 
suppuration, an early, energetic, and appropriate course of treat- 
ment, will enable us in many instances to avoid that sort of ter- 
mination. I think we should expect suppuration, unless we can 
see and treat the case early, in the first forty-eight hours, for 
instance, in severe cases, and not longer than four or five days in 
any sort of case. The antiphlogistic course must be tempered by 
the vital powers and sanguineous condition of the patient, as well 
as the intensity of the disease. When the disease is intense, the 
treatment must be as prompt and energetic as the patient can 
bear. And I would say to the student, the plan I shall now lay 
down supposes the patient to be plethoric and full of vital energy. 
Venesection in the upright position, to the approach of syncope, to 
be followed in ten or twelve hours, unless there is a decided miti- 
gation of the symptoms, with twelve or more leeches to the sacrum. 
The leeches may be again repeated in twenty -four hours, if neces- 
sary. The venesection should be followed immediately by a dose 
of eight or ten grains of calomel, or what would be better in strong 
patients, hyd. mit. chl., grs. viij, pul. Jalapa, grs. xij. This last 
would act copiously in a few hours. Supposing the case not to 
be broken down by this commencement, we may administer tinct. 
verat. virid. gtta. iv, every three hours, until the pulse is brought 
down below its natural frequency. After purgation has been 
free, if the pain is severe, there will be great propriety in giving 
pul. opii, grs. ij, hyd. mit. chl., grs. ss., every four or six hours, 
until a very gentle ptyalism is brought about. When the objects 
to be accomplished by giving the above treatment are attained, a 
blister over the iliac region most affected will be very appropriate. 
Not many instances, and these mostly puerperal, will demand or 
justify such energetic measures ; in severe and appropriate cases, 
however, much suffering will be avoided by them. In a more mod- 
erate grade of cases, or where the patients are less capable of 
bearing such energetic treatment, leeches or cupping to the 
sacrum, once or more as may J)e required, with the active cathar- 
tic, alterative, anodyne, and tinct. verat. virid., will suffice, provided 
they are used with promptitude. Fomentation and poultices over 
the affected region are always appropriate and beneficial. They 



300 PERIMETRITIS. 

are useful in every grade and stage of the disease. Very fre- 
quently, however, it is evident from the time we first visit the 
patient that suppuration is unavoidable. Or else we are in doubt 
about the possibility of avoiding suppuration. The treatment in 
such instances must be very different. Here it will be very proper 
to give the tinct. of verat. virid. in four-drop doses, every three 
hours, until the excitement of circulation is allayed, and then con- 
tinuing it at intervals at four or six hours, to keep it quiet. The 
anodynes and alteratives, as before directed, will also be in place, as 
well as the fomentations. As the remission of the fever with per- 
spirations denotes actual suppuration, our treatment should be 
tonic and anodyne until the case terminates. In the inflammatory 
stages the diet must be sparing and cooling, while in the suppurative 
stage more nutritious and stimulating substances should be admin- 
istered. We sometimes meet with patients broken down by indi- 
gestion and uterine suffering, or some other cause, that require 
general supporting treatment from the beginning, with the altera- 
tive, anodyne, and local, above-mentioned. They will profit by and 
require a sustaining diet also. 

A question arises at this stage of the affection which must be 
decided after a careful survey of the whole case, viz., should we 
evacuate the pus, or should this process be wholly left to nature ? 
As one of the disastrous terminations is a rupture in the perito- 
neal cavity, as nature often selects very circuitous and unsatisfac- 
tory viaducts, as the rectum, bladder, &c, and as a consequence of 
this last circumstance the recovery is very much protracted, I 
think we should, when practicable, furnish the pus an outlet of our 
own choosing, and as early as can conveniently be done. Soon as 
evidences of suppuration begin to be manifested through the gen- 
eral symptoms, we should make as thorough an examination as 
we can to ascertain where the collection has occurred. If one can 
discover the pus, we evacuate without apprehension of damage to 
any of the organs. If our first examination fails to satisfy us, it 
should be repeated as often as every twenty-four hours, until the 
discovery is made. When this is done, we institute one or two 
precautionary measures, w T hich will almost preclude the possibility 
of doing harm by an intelligent penetration. The first is to com- 
pletely evacuate the contents of the bladder and rectum by the 
catheter and an injection. We ought to be sure that the rectum 






PERIMETRITIS. 301 

is empty of fluid and gas. I knew fluid in the rectum to so far 
deceive a practitioner as to cause him to make preparation for its 
puncture. We ought to pass the catheter into the bladder and 
rectum after we sit down to operate. The next precautionary 
measure is to introduce the exploring trocar into the tumor, and 
after the pus has made its appearance, open the cavity by the side 
of the retained canula. In this way I think there is great safety 
in the operation. The patient may be prepared for the puncture 
by being placed on the left side before a good light, as if for oper- 
ation for vesico-vaginal fistula, and anaesthetized. The part may 
be exposed by Sims's dilator. The instrument most convenient for 
making the incision is a tenotomy knife. The opening should be 
free and direct, so as to permit of a ready discharge. The open- 
ing should not be allowed to close. This may be prevented by 
keeping a tent in the wound until the pus ceases to be discharged. 
The objects of thus opening the cavity are to secure an external 
and safe outlet, and its ready evacuation, and thereby attain a 
speedy cure and safety against peritoneal inflammation. When 
the chronic form consists in frequent repetitions of the inflamma- 
tion, on account, perhaps, of its imperfect subsidence, much may 
be done by persistent counter-irritation, and among the best kind 
is a seton in the groin kept running for months. An issue will 
have equal good effect. This permanent form of counter-irritation 
is better, I think, than blistering or pustulation. When the open- 
ing into the intestine or bladder becomes fistulous, as it sometimes 
does, and the discharge continues for months and even years if 
there is no vaginal opening, and the discharge is into the bowel or 
bladder, we should seek for a point in the tumor where it may be 
punctured, and the opening made free and direct through the 
vagina. If no such point can be found, we cannot, with propriety, 
interfere surgically. The openings are, however, often located so 
that we may easily reach them, as through the lower part of the 
abdominal walls, the labia, the gluteal region, the perineum, or 
vagina. If the. orifice is accessible, we may generally succeed in 
obliterating the suppurating cavity and fistulous canal. Prepara- 
tory to making an effort to do so, we should try to ascertain the 
tortuosities of the fistulous duct, and the depth of the pus-cavity. 
In some instances the canal is so crooked that the straight probe 
will pass but a very short distance, and it becomes necessary to 



302 PERIMETRITIS. 

send it in various ways ; and sometimes an elastic bougie will suit 
better for a probe than the ordinary metallic one. Prof. Simpson 
recommends leaving a wire in the track of the fistula until ad- 
hesive inflammation is excited. I have not tried this means, for I 
have been so well pleased with injections of iodine, that I have 
used them almost exclusively. I inject through a small-sized 
catheter. The smallest sized elastic catheter, pushed to the bottom 
of the cavity, will convey the fluid in its concentrated strength to 
the bottom, and thus produce the effect at that point. We ought, 
after introducing the catheter, to inject the cavity with tepid soap- 
suds, so as completely to cleanse the internal parts of pus, and 
then immediately throw up the solution. 

The undiluted tincture of iodine will not usually be too strong, 
and may be used once in three days, unless great inflammation fol- 
lows its injection. Sometimes the first injection does away with 
the production of pus, and produces adhesive inflammation. In 
order effectually to inaugurate the treatment, it sometimes, indeed 
generally, becomes necessary to slit up the orifice of the fistula 
somewhat, as it is usually smaller than any other part of the 
duct. 






CHAPTER XXI Y. 

DISPLACEMENTS OF THE UTERUS. 

From what I have already said, it will be inferred that, for the 
most part, I consider displacements of the unimpregnated uterus 
as complications and effects of inflammation; and that any other 
treatment but such as will remove the causing condition, is not cura- 
tive. The idea that they are primary affections, and require inde- 
pendent treatment, is so firmly rooted in the minds of patients and 
physicians, and the fact that we cannot always cure the uterine in- 
flammation and enlargement upon which they depend, and the fact 
that they do, in very rare instances, occur as the effect of appar- 
ently inscrutable causes, and consequently call for special treat- 
ment, render a separate consideration of these proper and necessary. 
It is plain that the notions in reference to the main item of treat- 
ment, viz., mechanical support, are too vague to be profitable to 
the novice. It will not be possible for me to enter into a very 
minute detail of such treatment, nor do I wish to be understood as 
trying to do anything more than suggest an outline of the principles 
that should govern us in the use of means for the relief of them. 
To do this satisfactorily, I must consider succinctly the different 
sorts of displacements, and, if possible, arrive at their mode of 
producing inconvenience and suffering, and their mechanical effects 
upon other organs, especially those in proximity to the uterus. I 
need not say that such considerations must also be imperfect, and 
assure the reader that they are merely intended to be suggestive. 

Many, if not most of the failures of mechanical support for the 
relief of displacements, depend upon a want of correct knowledge 
as to their nature in any given case, and consequently, of the right 
kind of instrument to be used, and the mode of applying it. It 
will be found, upon attentive examination of them, that displace- 
ments cause distress by pressing or dragging upon other organs, 
by taking away the support of other organs, and thus allowing 
them to be misplaced : as when it sinks low into the pelvis, the ab- 



304 DISPLACEMENTS OF THE UTERUS. 

dominal organs fall into this cavity to fill the vacuum; or when 
the os cervix or portion of the uterus is tender, causing distress 
by bearing on these places as it settles against the perineum, sa- 
crum, or rectum. In retroversion, for instance, the round liga- 
ments, broad ligaments, and bladder, are drawn more or less out 
of their place, and cause suffering; so with all other displacements, 
varying, however, in their respective effects. In addition to this 
the uterus may, in retroversion, press upon the rectum, and cause 
inflammation and pain in it; or, by stopping up this organ, cause 
costiveness and difficult defecation. Retroversion of the uterus, 
when the fundus or posterior wall is inflamed, causes suffering by 
the contact of the tender part against the rectum, sacrum, or 
perineum. 

Nature of Displacements. — The nature or doctrine of displace- 
ments of the uterus involves the conditions of its annexed organs. 
The uterus cannot be retroverted while the round ligaments retain 
all their natural conditions as to length, position, &c. Some parts 
of the vagina must also be changed in their conditions. So of pro- 
lapse ; the round, and particularly the broad ligaments, and the 
vagina, &c, must be made to deviate by the acting causes of these 
displacements, before these latter can occur. And it is not a ques- 
tion which is at fault, as though' the onus of failure in the functions 
appertained to either the ligaments or vagina, but which is most at 
fault. This requires us to decide which one of them does most to 
hold the uterus in place, which can be done only by distinguishing 
the kinds of displacement, and considering them with reference to 
this matter. The vagina can do but little to resist causes operating 
to produce retroversion or anteversion, but if narrow and rigid may 
strongly resist the tendency to prolapse. The ligaments seem so 
arranged as to resist displacements in every direction, and, except- 
ing anteversion, they are pretty firmly opposed to acting causes. 
Another point of importance in the doctrine of displacements is, 
the determination of the question, whether the displacements occur 
as the effect of relaxation of the sustaining organs, or whether the 
sustaining organs are relaxed on account of the long-continued ac- 
tion of the causes operating on the uterus. In most cases, I think, 
the last of these conditions obtains ; but, undoubtedly, they are 
quite frequently contemporaneous and consentaneous circum- 
stances. After labor, the ligaments and vagina must have re- 



DISPLACEMENTS OF THE UTERUS. 305 

turned to their natural and healthy dimensions and firmness be- 
fore they can resist displacing influences. This they cannot do 
for some weeks, and during this time the weight of the uterus, 
on account of imperfect involution, is much greater than they 
are in the habit of sustaining. Although usually at fault, be- 
cause overcome when in this natural condition, and forced into 
deficiency of function, they may, as the above view shows, be 
deficient because of their condition at the time the operating 
causes are applied. But we cannot always say that the uterus 
has fallen, or become displaced, because the ligaments and vagina 
are too weak or too lax to sustain it in place, but in many in- 
stances because the acting cause is sufficient to force them to over- 
come them, and carry the uterus' in the course of its action in 
spite of their healthy resistance. I think this is the true explana- 
tion which may be given in most cases. 

Depression or Lapse. — The principal and only important varie- 
ties of displacements are, first, a simple depression or falling of 
the uterus in the axis of the superior strait. The inconveniences 
resulting from this deviation are painful tenesmus, constipation, 
or hemorrhoids, on account of pressure upon the rectum ; sciatic 
pains, on account of pressure upon the sacral nerves ; pain in the 
uterus itself, on account of pressing upon its own tender cervix ; 
and feeling of weight on the perineum, and dragging about the 
loins and hips. The broad ligaments are stretched : perhaps the 
round ligaments somewhat increased in length, less so, however, 
than the others. The change in the direction of the vagina from 
almost directly backward to backward and downward, is also quite 
obvious. The rectification of this deviation is usually accomplished 
by lifting the uterus up. It requires no change in axial direction 
with the pelvis, but simply an elevation to restore the uterus to 
its proper place. 

Prolapse. — Secondly, prolapse in various degrees, from slight 
depression to complete extrusion from the labia. This displace- 
ment in the slightest degree, and in fact in all its degrees, pulls 
upon and stretches all the ligaments, the broad ligaments by far 
the most. The vagina suffers displacement proportionally with 
the prolapse. It is inverted, its walls being doubled upon them- 
selves, and its cavity progressively shortened until entirely effaced. 
This displacement is always in a direction corresponding with the 

20 



806 DISPLACEMENTS OF THE UTERUS. 

axis of the vagina and different portions of the pelvis, and follows 
the curve formed by the hollow of the sacrum and continued by 
the perineum. The inconveniences arising from this displacement 
are not unlike the last, until it becomes great, when the bearing 
down becomes more distressing, as well as the dragging on the 
loins. To these are added those arising from a prolapse of the 
abdominal viscera into the pelvic cavity ; sinking sensation in the 
epigastric region, and dragging upon the hypochondria, &c. The 
means calculated successfully to restore the uterus in this displace- 
ment must lift it up and correct its axial deviation. 

Retroversion.- — Thirdly, retroversion. This displacement is pres- 
ent when the fundus is depressed by being thrown back into the 
hollow of the sacrum, while the cervix is drawn forwards and up- 
ward, so as to be upon a level, or above a level with the arch of 
the symphysis pubis. The difference between this and prolapse 
is, that the fundus is thrown lower down into the hollow of the 
sacrum, and the axis of the uterus is almost natural, but the 
lower end becomes the upper. The inconveniences arising from 
this displacement are caused by pressure on the rectum, perineum, 
and sacral nerves in the posterior inferior part of the pelvis, and 
sometimes pressure upon the neck of the bladder or urethra in 
front, and dragging upon the ligaments. The ligaments most 
severely stretched are the round, the broad being much less so. 
The condition of the vagina is changed very considerably ; the 
anterior wall is very much shortened, while in married women the 
posterior is elongated somewhat. The means employed for the cor- 
rection will act by elevating the fundus and pressing the cervix 
backward towards the middle of the pelvis. 

Anteversion. — Fourthly, anteversion is, in most respects, nearly 
the opposite in position. The cervix is turned back upon the sa- 
crum, and elevated somewhat above its natural position, while the 
fundus is thrown forward upon the bladder and anterior walls of 
the vagina, so as to come down to a level, or nearly so, with the 
arch of the symphysis pubis. The inconveniences arising from 
this displacement are caused by pressure upon the bladder, ure- 
thra, and rectum, tenderness in sexual intercourse, and dragging 
about the pubis. The broad ligaments are stretched most, and 
the vagina is elongated and depressed somewhat at its posterior 
extremity. Not unfrequently the rectum is pressed upon by the 



DISPLACEMENTS OF THE UTERUS. 307 

cervix uteri, and distress arises as a consequence. The means for 
rectifying this position must lift the fundus upward, and push it 
backward, or draw the cervix forward and lift it slightly upward. 

Causes. — Anything that will increase the weight of the uterus 
predisposes it to deviations and displacements. When thus pre- 
disposed by increased weight, if the patient is much in the erect 
posture, the uterus will settle down into displacements. It will 
be observed that the deviations I have mentioned are lapses in 
some manner or form. When the uterus is slightly enlarged and 
increased in weight, the erect posture is not always enough to 
cause displacement, but if the patient strain from the tenesmus of 
dysentery or dysuria, or in lifting, or is jolted so as to bring the 
weight of the abdominal viscera down upon the pelvic organs, she 
feels a distressing sense of pressure upon the perineum, rectum, 
or bladder, or all of them, and thenceforth she suffers from some 
of the disagreeable symptoms attendant upon the displacement. 
Should the uterus be much larger than natural, the erect posture 
maintained for any length of time insures a displacement. In- 
flammation of the cervix is almost always attended with increased 
size and weight of the whole uterus, and thus it predisposes the 
organ to displacement. This accounts for the fact that we very 
often find these two conditions present. I have no doubt, from 
ample observation, that inflammation is very frequently the cause 
of depression and other displacements in this way. Dr. Bennett 
thinks that when inflammation attacks the posterior walls of the 
uterus, retroversion is the result, and that anteversion is caused 
by inflammation of the anterior wall, and leaves us to infer that 
these displacements are almost always connected with inflamma- 
tions as an effect. While I believe with him that these displace- 
ments may result from inflammations thus localized, they are, I 
am satisfied, often caused by inflammation of the cervix alone, 
and that without any peculiarity discoverable by an examination. 
I think I have seen every variety of displacement connected with 
cervical inflammation. 

Imperfect Involution. — Imperfect involution is another cause 01 
displacements. Involution may be imperfect and yet be progress- 
ing naturally when a co-operating cause determines displacement. 
If, for instance, a woman who has given birth to a child, arise 
from the bed in four or five days and maintains the erect posture 



308 DISPLACEMENTS OF THE UTERUS. 

for a length of time, or remain permanently out of bed, engaged 
perhaps in some arduous duties on her feet, the uterus, being still 
so much above its natural size and weight, falls in some manner 
in spite of the relaxed ligaments and vagina. This is the manner 
in which some persons contract uterine displacements after labor. 
Arrest of Involution. — But it occasionally occurs that long after 
the usual time for involution to be complete, the uterus remains 
increased in volume and weight, because of the arrest or the tardi- 
ness of this process. In this condition, the uterus is liable to set- 
tle below its natural level, in part or as a whole. Subacute in- 
flammation, attacking the post-parturient uterus, not unfrequently 
delays the return of this organ to its natural dimensions for 
many weeks after confinement. In all these last cases, the dis- 
placement occurs at a period not very remote from parturition or 
abortion. And very many cases can easily be traced to this time, 
or near it, seeming to be a sequence to it. I cannot forbear re- 
marking here, with reference even to these cases, that when they 
have become chronic they are found to be complicated with inflam- 
mation; and that where this can be removed entirely, the restora- 
tion of the position of the uterus generally takes place spontane- 
ously, and is easily effected by treatment, or ceases to present any 
indication for treatment, on account of the absence of symptoms. 

Tumors. — Tumors, developed in some part of the fibrous struc- 
ture, cause an increase in weight, and thus encourage, at first, 
displacement, and after awhile determine it. The position of the 
tumor will govern the nature of the deviation. If the tumor is in 
the anterior wall, it is apt to cause anteversion; if in the posterior 
walls, retroversion ; if in the cavity or cervix, prolapse, or merely 
lapse. 

Loaded Intestinal Canal. — With the causes above spoken of 
predisposing to it, I think the pressure of heavily loaded intestines 
may determine displacement. Fecal accumulations in habitual 
constipation would be sufficient. 

Distended Bladder. — Equally, perhaps more certainly mischiev- 
ous, is a bladder constantly filled with urine overriding the uterus, 
and pressing backward and downward. This cause would seem to 
favor retroversion, on account of the position of the bladder. 
These eauses are undoubtedly not sufficient, however, to produce 



DISPLACEMENTS OF THE UTERUS. 309 

permanent displacement, without the co-operation of increased 
weight of the uterus. 

Symptoms. — However the displacements may occur, the symp- 
toms attendant upon them will not enable us to distinguish one 
from the other. As I have already shown, certain deviations very 
often give rise to particular symptoms; but this is not so con- 
stantly the case that our diagnosis can be materially influenced by 
them. It is true, also, that the symptoms cannot be distinguished 
from symptoms arising from other pelvic diseases; hence there is 
no alternative left us : a physical examination will be our only suf- 
ficient means for forming an accurate diagnosis. The symptoms 
are an expression of the sufferings of other organs, for the most 
part from pressure on them by the uterus. Pain, numbness, de- 
bility, formication, or change of temperature, general or partial, 
of the lower extremities, or one of them, on account of the pres- 
sure upon some of the large nerves, particularly the sciatic run- 
ning down them, or tenesmus, constipation, hemorrhoids, and 
sense of heat or weight in the rectum, indicates the pressure upon 
that bowel. The dysuria, cutting, burning, or rending pain in the 
bladder, incontinence of urine, and other distressing vesical dis- 
orders, are expressive of the suffering caused by pressure on the 
neck of the bladder or urethra by the displaced uterus. But a 
general pelvic tenesmus, or feeling of bearing down, with weight 
and dragging upon the perineum, not unfrequently are produced 
or aggravated by the uterus lying heavily upon the bottom of the 
pelvis. This is perineal distress. There is also a general feeling 
of pelvic distress, such as dragging pain in the hips and loins, 
weight and pressure about the pubis, a feeling as of a cord draw- 
ing in one or both of the inguinal regions, or general sense of 
weakness and indescribable malaise. Another sort of difficulty 
seems to be produced by the uterus in its descent, dragging other 
organs out of their natural position. The bladder may be thus 
drawn down, and cause a sense of dragging from the umbilicus, or 
produce various sorts of trouble in the functions of holding and 
evacuating the urine. 

Prolapse of Ovaria.—The ovaria are displaced and drawn down 
into the pelvis, with the feeling of tension in the broad ligaments, 
or iliac regions. In extreme cases of prolapse, and even sometimes 
in the slighter degrees of displacement, disagreeable symptoms 



310 DISPLACEMENTS OF THE UTERUS. 

arise from abdominal organs falling into the pelvis to fill the par- 
tial vacuum caused by the descent of the uterus. To this cause, 
doubtless^ may sometimes be justly attributed the sense of weak- 
ness and emptiness in the epigastrium, and the pain in the side, in 
the region of the liver and spleen. 

What is more common, however, is the suffering caused by the 
inflamed uterus, slightly depressed, pressing upon its own sensitive 
diseased parts, as the cervix, posterior wall, or even fundus. 
Again, there can be no doubt but that the rectum, bladder, cel- 
lular tissue within the pelvis, and parts surrounding the nerves, 
and even the nerves themselves, are often subjects of inflamma- 
tion, and, being pressed by the inflamed, enlarged, and sensitive 
uterus, are much more susceptible to the above described influences 
than if they were all in their ordinary healthy condition. 

Examinations to determine displacements should be both digital 
and instrumental, and thorough enough to ascertain the particu- 
lars as to the position and condition of the uterus in all other re- 
spects that can have any bearing upon the case. 

When very great suffering of the character above mentioned 
exists, there is almost always a combination of inflammation and 
displacement. Should there be any obscurity in the position of 
the uterus, on any account, our diagnosis may be cleared up to a 
demonstration by introducing the probe into the cavity of the 
organ. The direction the instrument takes will clearly show the 
direction of the uterine cavity, and thus indicate the position of 
the organ. 

Treatment of Displacements. — The efficacious mode of treating 
displacements, as I have before intimated, is the perfect removal 
of the causes of them. When this can be done completely, the 
inconvenience and suffering attributed to them are removed, or 
very materially ameliorated. But there are cases where this 
cannot be done, from various reasons, among which are the preju- 
dices of patients and medical men against the treatment necessary 
for the cure of inflammation, the impossibility of curing the in- 
flammation when every opportunity is enjoyed, and even sometimes, 
when the inflammation is removed, so far as we can judge, there 
may be a continuance of displacement with its symptoms. In all 
or most of these, the skilful treatment of the cases, as displace- 
ments, will often result in great palliation, if not in cure. All I 



DISPLACEMENTS OF THE UTERUS. 311 

need say here in reference to the treatment of inflammation is, 
that full directions may be found in the foregoing chapters on that 
subject. 

Treatment of Deficient Involution. — Involution as one of the 
causes, should be treated as subacute inflammation of the wliole of 
that organ. All the symptoms, as we usually find them, will jus- 
tify this procedure. It is, in fact, subacute inflammation occurring 
in the uterus after accouchement, and operates in establishing dis- 
placement upon first getting up from childbed. To avoid this con- 
dition by sufficient quiet and care, is much easier than the cure 
after the disease is established. When it does exist, rest in the 
horizontal position, alteratives, laxatives, external fomentation, 
counter-irritation, &c, will ordinarily relieve it, and prevent or 
cure the mischief done or apprehended. 

Removal of Tumors. — When the uterus is enlarged or depressed 
by tumors, their removal is the only radical way of overcoming the 
difficulty. If a loaded condition of the bowels is the operating 
cause, we must endeavor, by alteratives, laxatives, &c, to remove 
this condition. 

Mechanical Support. — The main object I had in view in intro- 
ducing this chapter on displacement, was to discuss the subject of 
mechanical support. And as an introduction, I may state my con- 
viction, that very few general practitioners study these affections 
sufficiently to acquire the skill requisite for the best management 
of them. Too often we are satisfied with merely recommending 
some form of supporter or pessary, and leave the execution of our 
designs to the patient or her friends. There is too much care- 
lessness in this respect to form a proper estimate of the nature of 
mechanical support for the uterus. Believing these statements to 
be true, I have ventured to attempt to describe, in a very concise 
manner, as far as they have been suggested to me by a large ob- 
servation and a careful study of the subject, the conditions which 
give direction to the particular kinds and modes of using these 
contrivances. 

Two Kinds of Mechanical Support. — There are two general kinds 
of mechanical contrivances for the purpose of support. 

Abdominal Supporter. — The first which I shall mention is the 
abdominal supporter. It is made of various shapes, sizes, and ma- 
terials. The object is to lift the abdominal organs off the uterus 



312 DISPLACEMENTS OF THE UTERUS. 

and its appendages, and support them so that they cannot press 
the latter into the pelvis. 

Rationale of their Action. — It will be remembered that the inner 
face of the pubis looks obliquely upward and backward, forming 
the base of support for the abdominal organs. These latter press, 
on account of the inclined position of the pelvis, obliquely upon the 
uterus, instead of perpendicularly. The farther back the pubis is 
pressed toward the sacral promontory, the more completely beneath 
the abdominal organs, the more certainly they rest upon the upper 
portion of the inner face, and the less they press into the pelvis. 

Abdominal supporters are intended to, and fulfil their purposes 
best when they aid the pubis in this function. One indispensable 
portion of them consists in a plate or pad, so arranged as to press 
the abdominal muscles immediately above the symphysis as far 
back toward the promontory of the sacrum as possible. This 
plate, pushed in above the symphysis and below the intestines, 
prevents them from weighing heavily upon the pelvic viscera. 
And when it is recollected that it requires, in most persons, a very 
little intrusion of this plate or pad into this part of the abdomen 
to intercept a line falling through the central part of the trunk 
above, and thus to assume a position for the support of the abdom- 
inal organs, we can see how it might be efficacious in certain in- 
stances, and nearly harmless in all. The plate or pad is pressed 
to its place, and held in position by springs or bandages variously 
arranged to suit the fancy of the contriver. Connected with the 
springs which pass around the hips, not unlike the springs of a 
truss, is a pad that bears upon the back, so as to press the loins 
forward, and thus incline the face of the pubis more to the hori- 
zontal. The cases to which properly formed abdominal supporters 
are applicable are not numerous ; but there can be no question 
about their utility as a means of ameliorating the distress some- 
times experienced on account of pressure on the top of the pelvis, 
and on the pelvic viscera by the abdominal organs. The obser- 
vation of the profession has not settled into rules as to. the man- 
ner of using these supporters, nor are they used at all by many 
of the most intelligent members of the profession. Yet I am per- 
suaded that in certain instances where we are under the necessity 
of confining our efforts to palliation, the supporter, judiciously 
selected, adapted, and applied, will afford relief that cannot be ob- 



DISPLACEMENTS OF THE UTERUS. 313 

tained by any other means. There are many circumstances and 
conditions to be studied as indices to the kind of instrument appli- 
cable, its mode of use, and as affording data by which to judge of 
the practicability of any kind. These considerations should be 
studied in each case. Thin persons with large pelves, who stoop 
habitually forward, are the sort of patients, as a general thing, 
whose shape and condition render them applicable ; while fat, erect 
women do not profit by them. These conditions are mentioned 
irrespective of the special affections for which they are recom- 
mended. Their adaptability depends, further, upon the complete 
absence of tenderness of the hypogastric region, or of great sen- 
sitiveness from any cause in any portion of the body upon which 
any part of the instrument may press. The firmness of the ab- 
dominal muscles may also prevent the supporter from having its 
proper effects. But notwithstanding the fact that the case and 
the patient may be suitable, so far as we can judge, a trial will be 
the only means of deciding the adaptation. I hope the profession 
will try more patiently and philosophically this means of pallia- 
ting the sufferings of women, when we cannot cure the diseases 
which give origin to them. 

Its Value. — It is needless, after what I have said above, to 
state that I consider the abdominal supporter but a make-shift, 
and useful as a palliative only when radical means cannot, for 
any reason, be used or relied upon. Unfortunately, these are too 
numerous to be allowed to go unprovided for. 

Supporter and Pessary combined. — They are sometimes avail- 
able as external attachments to pessaries, thus keeping these last 
in place, and making them more completely fulfil their special 
purposes. The combined abdominal supporter and pessary, when 
they can be borne, make an efficient means of rectifying displace- 
ments. The perineal pad so often attached to the supporter, al- 
though more easily worn and less likely to do damage, is also less 
efficient than a suitable pessary in the vagina, kept in place by a 
spring coming down in front from the front pad of the supporter. 

Pessary. — The pessary, however, is much more commonly used 
alone than in combination with any other means of support. This 
instrument is made of various materials, and in many different 
shapes ; the grand object of all of them is to maintain the uterus 
in its proper place and position. They are direct supporters of 



314 DISPLACEMENTS OF THE UTERUS. 

the organ by touching the uterus in some part, and by the con- 
tact holding it in place, or' support it by converting the vagina 
into ligaments of support. 

Ring Pessary. — The ring pessary, for instance, by distending 
the vagina all around the cervix, supports the uterus upon a level 
with its own circle, thus lifting it off the perineum, rectum, or 
nerves at the bottom of the pelvis. The ring pessary, by pressing 
upon the vagina, and drawing it upward and backward, is calcu- 
lated to correct some inclinations of the uterus as well as to lift it 
up in place, as in cases of retroversion particularly. 

Stem Pessary. — The stem pessary, as it is introduced in part 
into the cavity of the uterus, if properly adapted also corrects all 
sorts of deviations. It should have a perineal flat support, or be 
attached to some external means of maintenance. It is the most 
perfect mechanical support we can make use of, for if adjusted in 
accordance with a just knowledge of the natural place and posi- 
tion of the uterus, it is certain to prevent it from departing from it. 

Globe Pessary. — The globe lies immediately behind the pubic 
bone, presses upon the anterior wall of the vagina and uterus, lift- 
ing the fundus upward and backward, and, when sufficiently large, 
raises the whole uterus by drawing upon the anterior wall of the 
vagina. 

Oval. — The oval occupies the same position in the vagina, and 
operates the same way when it lies crosswise, immediately behind 
the rami of the pubis and ischium. 

Disk. — The disk with convex depression in the centre merely 
lifts the organ up from the perineum by its thickness. It lies 
under the uterus, in the centre of the pelvis, and is perpendicular 
in its action. It is incapable of correcting any other malposition 
than depression or prolapse. The gum bag, distended with air, of 
all these shapes, globular and circular, diskal and oval, of course 
operates as I have described these. Notwithstanding the above is 
a general, and, for the most part, correct idea of the modus ope- 
randi of the different shaped pessaries, in no two cases will the 
same formed pessary have precisely the same bearing above and 
below, and consequently these items cannot be attended to in each 
different case. There is, in other words, an individuality in every 
case of every sort of deviation, that will require for it separate 
study. This instrument is not only made in different shapes, but 



DISPLACEMENTS OF THE UTERUS. 315 

there is a diversity of material used for its construction. Several 
of the metals, as gold, silver, copper, steel, &c, enter into the com- 
position of pessaries : horn, wood, ivory, India-rubber and gutta- 
percha, are also made use of. These two last are worked with so 
much skill, of late years, that the'y are taking the place of other 
material in the manufacture of pessaries. The hard and soft rub- 
ber pessaries are assuming almost every variety of shape. Al- 
though it is quite impossible to give directions that will be appli- 
cable to all sorts of cases, and much must always be left to the 
judgment of the attendant, I venture to hope that the few general 
considerations which I shall submit will awaken intelligent reflec- 
tion in the mind of the student as to the difficulties that will often 
present themselves, and sometimes entirely baffle him in the use 
of the pessary. 

Preparation of the Vagina. — It should be remembered that the 
vagina will frequently need preparation before it will tolerate the 
pessary. How unreasonable it would be to introduce the globe, 
oval, disk or ring pessary into the vagina, and expect it to toler- 
ate the presence of any of them, when it was in a state of inflam- 
mation, great contraction, or rigidity. These conditions, if pres- 
ent, should be removed before attempting the use of any pessary. 
When this is not practicable, we should not think of using the 
instrument. A condition of the vagina most tolerant of the pes- 
sary, but which often thwarts our best considered plans, is a very 
lax state of its walls or sphincter. This relaxation sometimes 
obstinately persists, in spite of every effort to remove it. By at- 
taching external supports to the pessary, in these cases, we may 
keep it in position, and thus compensate for the absence of the 
co-operating support of the vagina. 

Condition of the Uterus that modifies the Use of the Pessary. — 
These considerations as to the state of the vagina have but little 
reference to the kind of instrument, either in shape, size, or mate- 
rial ; but there is another class of circumstances that will govern 
us in the selection of a pessary. These have reference to the suf- 
fering organ, and the mode in which the suffering is produced. 
Where is the pressure ? What organ is pressed upon, and by 
what part of the uterus is the pressure made ? Does the rectum 
suffer by the pressure of the cervix, as the uterus stands in the 
direction of the axis of the superior strait ? If so, the uterus 



316 DISPLACEMENTS OF THE UTERUS. 

must be lifted clear of it by an instrument that will not press 
upon the rectum in the same place, or the symptoms will be con- 
tinued, and even aggravated by the pessary. If the rectum suf- 
fers by the fundus turning backward upon it, the fundus must be 
raised forward, without making the rectum a point of support for 
the instrument which does it. In like manner, if the pressure is 
upon the sacral nerves, perineum, bladder, &c. In any or all of 
these cases the uterus may be tender or inflamed. If this is the 
case, the pessary must be so constructed as not only to avoid 
pressure upon tender points of the subjacent organs, but likewise 
to impinge upon the uterus at a sound portion, or support without 
touching it at all, else the symptoms will be only partially re- 
lieved, or changed somewhat in their character. When it is re- 
membered that all of these conditions are to be fulfilled in order 
to get a perfect adaptation of the pessary, it will not be surpris- 
ing that we so often fail in getting good from its use, that there 
is so great a variety in shape, consistence, size, &c, that definite 
rules are impossible, and that so few practitioners agree in regard 
to their usefulness and adaptation. The pessary must be studied 
as a mechanical instrument, while its use subserves physiological 
purposes. It must be governed by mechanical laws, with the infi- 
nite and inappreciable exceptions which physiology always im- 
poses upon them. 

Kind of Displacements to which it is Adapted. — Another set of 
considerations must have reference to the mere displacement : as 
to whether it is retroversion, anteversion, prolapse, lapse, &c. On 
these last considerations will, more than any others, depend the 
shape of the pessary. It will sometimes be found difficult, if not 
impossible, to employ an instrument that will correct displace- 
ment without its making pressure on the suffering organ at the 
side of, or beneath the uterus, or upon a tender point in this organ 
itself. When such is the case, the consistence or hardness is a 
matter of much importance. A pessary filled with air or stuffed 
with hair is a better point of support for a tender uterus than a 
hard rubber, glass, or metal instrument. The former kind are 
cushions of such softness as sometimes to be tolerated by a very 
tender organ. A deliberate attention to the above considerations 
will enable us to approximate more nearly to an adaptation than 
a more loose and less methodical study of each individual case ; 






DISPLACEMENTS OF THE UTERUS. 317 

and while it may not lead us at the first experiment to perfection 
in this respect, it will form a basis for intelligent experimentation. 
And it should be expected that not only will such study, but ob- 
servation also, in each instance, be necessary to arrive at a per- 
fect adaptation. 

The instrument which, mechanically speaking, is best calculated 
to correct all sorts of deviations, as well as to keep clear of sur- 
rounding organs, and consequently not to cause distress in them, 
by pressure upon them, is the stem pessary with external support. 
It in fact completely fulfils every mechanical .indication in any 
species of deviation. This is the case, because the stem fitting into 
the cervical cavity, and even passing up into the cavity of the 
body, forms a lever when fixed in a certain position by a branch 
passing out between the labia to be connected with a fixed support 
externally, and it must keep the uterus precisely in place. Un- 
fortunately for our success in these cases, this mechanical con- 
trivance is quite intolerable under most circumstances. The rea- 
sons why it is intolerable are that the pressure of the stem upon 
the mucous lining of the cavities causes inflammation, and a posi- 
tively fixed state of the organ is unnatural, and in some postures 
and movements of the body, must be annoying to other organs by 
interfering with their mobility. 

The elastic ring made of a watch-spring covered by gutta percha, 
or some other impervious material, when properly adapted in size 
and strength to the size of the vagina, and well applied, is also a 
very efficient instrument, and applicable to almost all varieties of 
deviation. It spreads the vagina out on all sides, and causes the 
walls of this tube to assume almost the same relation to the lower 
part of the uterus that the broad ligaments do to the upper part 
of the organ. This imitation of the pelvic circle by the ring and 
its ligaments, stretching the vagina around the uterus, keeps the 
cervix in position, provided the vaginal walls are made tense by 
the size of the ring. When the broad and round ligaments are 
lax, however, the fundus and body are left to topple over back- 
ward to the sides or in front, and if these are heavy, it may dis- 
tress the rectum or bladder. The ring pessary may be made to 
replace the uterus in retroversion or prolapse, better, perhaps, than 
any others, but is not calculated to be of any advantage in ante- 
version. It is not so likely to produce intolerable irritation as the 



318 DISPLACEMENTS OF THE UTERUS. 

stem pessary, and, in fact, may be made to agree with cases as 
well as almost any other kind of instrument. The size of the ring to 
be used will depend upon the size of the pelvis, and the tension of 
the vagina. If the vagina is cylindrical, firm and elastic, not rigid, 
free from inflammation, and not particularly sensitive, we may hope 
to procure toleration for the ring. It must be placed so as to suit 
the case. If the deviation is prolapse, the ring should be placed 
so that one part of its circumference be at the arch of the sym- 
physis, while the other side is directed to the sacrum, so as to cor- 
respond with the axis of the pelvis upon a level with the lower 
part of the symphysis. For retroversion, the posterior part of 
the circle should be directed up the sacrum toward the promontory, 
while the anterior part is placed below the arch of the symphysis. 
It will be seen that the indications are fulfilled by thus accommo- 
dating the position of the uterus by the position of the instrument. 
In the latter position, the fundus of the uterus is raised up by the 
ring pressing the posterior cul-de-sac of the vagina up behind it, 
while the os is drawn backward by traction on the posterior wall 
of the vagina. In retroversion, the stretching of the vagina from 
before backward is usually sufficient, and it is not necessary to 
distend it laterally to the same extent, if at all. 

Dr. Hodge's modifications of the ring pessary, called by him the 
open lever, may often be substituted for the -ring, and in some 
cases, perhaps, acts better than it. Dr. Hodge's pessary is sub- 
stantially a flattened ring. It is made of firm material, and curved 
so that it may be made to distend the posterior vaginal cul-de-sac 
by curving up behind the uterus, thus lifting the fundus and draw- 
ing back the os uteri. This pessary, according to the inventor, is 
capable of doing more good and is of greater extent of adaptation 
than the elastic ring. As it is in the hands of an intelligent and 
discriminating profession, these assurances will be tested and de- 
cided upon no doubt correctly. I confess that I am decidedly in 
favor of the elastic ring, which, if not too rigid, moulds and adapts 
itself to the inequalities of the parts, allows a limited movement 
to the uterus, and yields to the passage of faeces down the rectum, 
none of which things are accomplished by Dr. Hodge's pessary, 
which is unyielding and fixed in its position, and inelastic in com- 
position. Dewees's modification of the ring — the disk — is more 
clumsy, and I think less useful than the ordinary ring of some 






DISPLACEMENTS OF THE UTERUS. 319 

elastic material. I have seen this form of instrument made of 
hollow elastic material, and supplied with a tube for inflation. 
The instrument thus formed is introduced, placed in position, and 
then inflated. Or it is sometimes inflated when manufactured, and 
kept so permanently, and used as the hard rubber or glass made 
by Prof. Dewees. The common air-bag, of different forms and 
dimensions, is made with a supply-tube for filling. This air-bag 
forms a soft cushion, upon which a tender uterus may rest without 
much offence to its susceptibilities. It also diffuses the pressure 
over a large space, in such a way as to relieve the distress of other 
inflamed and injured organs. There are other forms of pessaries 
recommended for, and perhaps have, their special virtues ; but it 
would be both profitless and tedious to enumerate more of them. 
The globe pessary is best adapted to the correction of anteversion, 
and perhaps none other will answer so well. It is not appropriate 
in any other form of displacement. It is necessary to understand 
the principles which govern their application: study well each case, 
and then, if there is no instrument at hand that suits, make such a 
one as is adapted to the case for which it is needed. There are 
but few persons, who will take time to think upon the instances in 
hand, but will be able to judge of and adapt the proper instrument. 
It is a question, after we have adapted an instrument in a favorable 
manner to a case suited, what should be the management of it. 
The kind of instrument, and the nature of the case, must determine 
this question, instead of an arbitrary rule. A pessary made of 
porous material, that entangles the secretions, will soon become 
foul with them, and hence should be often removed and cleansed. 
This should be done, for instance, every twenty-four hours. In 
case of the ring made of hard and polished material, there is no 
need of frequent removals, as they do not absorb or entangle the 
mucus, pus, or blood. A profuse discharge of blood, mucus, or 
pus, will render an instrument that is capable of becoming so, fit 
to remain in for only a short time. Much tenderness and inflam- 
mation is a good reason for keeping both the pessary and vagina 
clean; but the same states forbid the frequent removal and intro- 
duction of the instrument, on account of the violence thus done. 
The presence of the pessary need not prohibit the use of medi- 
cated injections in the vagina ; or, if we think best, the pessary 
may be medicated, or made the medium of applying medicines to 



320 DISPLACEMENTS OF THE UTERUS. 

the vaginal membrane. Of course, the composition of the pessary 
should be taken into consideration, lest chemical reaction between it 
and the injected substance occurs. It should not be incompatible 
with the nitrate of silver, acet. lead, sul. zinc, or with whatever 
may be used. Carelessness or ignorance, or both, in the use of the 
pessary, may lead to disastrous damage from them. They should 
be properly attended to. When allowed to remain too long in the 
vagina, charged with blood, mucus, or pus, which becomes entangled 
in them or detained about them, its decomposition becomes a source 
of poisonous filth, that, by absorption, may endanger the life of the 
patient, and most certainly will be an intolerable annoyance. Or, 
by continued and prolonged pressure on some particular place, the 
pessary may cause ulceration to destruction of much tissue, cre- 
ating fistula, urinary or fecal. It is but proper and just, however, 
to observe in this connection, that these results are the effects of 
the abuse of the pessary, and should not be brought forward as 
objections to its judicious use, any more than cutting the intestine 
should be regarded as prohibitory of operations for strangulated 
hernia. Carefulness will, no doubt, prevent all the evil effects 
which have been done by the pessary ; and when the damage can- 
not be avoided, no judicious practitioner will persist in their use. 
They are not, in such cases, the means adapted to the end. 

Procidentia or Protrusion of the Uterus. — 'What has been said 
about the moderate displacements is not sufficient to enable the 
student to understand those extreme cases in which the uterus, 
vagina, and the bladder, are more or less completely protruded 
from the pelvis through the vaginal orifice, and it will be profitable 
I think, to consider them more at length. 

Nature and Causes. — Whatever may be our theory as to the in- 
itial condition under which procidentia arises, there can be no 
question that there always are three very important, indeed, in- 
dispensable items in the complete case. There must be, 1st. Great 
relaxation of the lateral, sacral, and round ligaments. 2d. Re- 
laxed or deficient perineum. 3d. Hypertrophy and relaxation 
of the vagina. I do not contend for the order in which they are 
here mentioned, but it is manifest that the uterus will not appear 
externally where the ligaments are not longer than natural, nor 
can it crowd down and drag along with it the bladder and the in- 
verted walls of the vagina, when this last canal is only of its or- 



DISPLACEMENTS OF THE UTERUS. 321 

dinary dimensions, neither will it protrude with the perineal mar- 
gin intact, and in its proper place. So that it is too restricted a 
view of the subject to say that protrusion depends upon a relaxed 
vagina alone, and rely upon a diminution of its calibre as a suffi- 
cient cure in all cases, because if both the other conditions continue, 
the vagina may be relaxed and the evil renewed. A similar re- 
mark may be made with reference to deficient perineum. 

One of the three conditions may preponderate in its influence, 
and its correction may possibly cure the case, but it is quite likely 
to fail. An aggravating but not always present condition is en- 
larged and unduly heavy condition of the uterus : I say not always 
present, for sometimes the uterus is even less than the ordinary 
weight and size. Although the pelvis is often larger, and the arch 
of the pubis more expanded than usual, they are not always so. 
If the three essential conditions above mentioned are present in a 
sufficient degree there will be procidentia. It is an easy matter 
to see that any one of those conditions in an extreme degree may 
induce the others, and will be likely under favorably acting exter- 
nal causes to do so. It is very probable, also, if not certain, that 
a permanently enlarged uterus, weighing considerably more than 
natural, will bring about all the three essential conditions. Preg- 
nancy succeeded by parturition brings about hypertrophy and 
elongation of all the ligaments, hypertrophy and relaxation of the 
vagina and perineum, and in a large per cent, of labor, the peri- 
neum is not merely relaxed and hypertrophied but torn so as to 
leave a deficiency of it. Such states of all the parts may become 
permanent and allow descent. These conditions may be brought 
about by many different causes. Vesical or rectal tenesmus, long 
continued, are powerful causes. Dr. McClintock in his recent 
work on Diseases of Women, details a case which seemed to have 
been caused by the tenesmus of stricture of the rectum. From 
the action of the different causes it will sometimes take place sud- 
denly, sometimes slowly. If the uterus is heavy, as after partu- 
rition or abortion, it is more likely to be sudden. ■ 

The extent of protrusion is sometimes very great. Usually the 
uterus is protruded as far as the length of the vagina will permit, 
and within this inverted cavity are contained the uterus and part 
of the bladder above. At other times the tumor is immensely large, 
reaching halfway to the knees, containing the uterus, bladder, ovaria, 

21 



322 DISPLACEMENTS OP THE UTERUS. 

Fallopian tubes, and a large amount of the intestines. The vaginal 
mucous membrane is almost always more or less changed. It is 
generally dry, rough, and dark colored. In some instances it is 
inflamed, sensitive, and even ulcerated. Large deep excavating 
ulceration of the cervix and vagina are not at all uncommon. The 
intensity and extent of the inflammation and the gravity of ulcera- 
tion exceed what is to be found in any other chronic non-malignant 
condition of the organ ; from which it is rational to conclude that 
in this instance, at least, the misplacement causes the inflammation, 
or at least very much aggravates it. Still stronger support to this 
inference is the fact that, to return and maintain the uterus in 
its natural position, these conditions are immediately ameliorated, 
and as a consequence sometimes entirely cured. The protrusion 
does not seem to incapacitate the organ for the discharge of its 
natural functions. Menstruation is often quite natural, impreg- 
nation practicable, and labor proceeds favorably. Whether the 
protrusion ever occurs for the first time during pregnancy, from 
my own observation I am unable to say, but I have seen instances 
when it continued during the whole period of gestation. About 
four years since, I attended a patient whom I saw frequently during 
pregnancy ; and up to the time when labor began, the cervix pro- 
truded three inches beyond the vulva, and only receded after the 
head began to descend. It then passed entirely within the exter- 
nal organs, and labor was accomplished as usual. Another in- 
stance I observed in the person of a German woman, who had been 
the subject of this displacement for many years. She was taken 
in labor with her tenth child, at the end of the seventh month ; the 
uterus did not ascend during labor, but seemed to be driven further 
down by the action of the abdominal muscles, until it must have 
protruded six inches through the vulva, and I saw the head of the 
child preceded by the bag of water, pass through the mouth of the 
uterus entirely out of the pelvis. And the whole child passed 
through the pelvis before it passed the mouth of the womb. I have 
attended probably a dozen labors in women laboring under excessive 
protrusion, and they have never been embarrassed in the least by 
this unfortunate circumstance. It is a matter of some interest to 
know how well these patients bear up under their suffering, some- 
times being capable of much useful exertion, indeed not apparently 
more distressed than by the chronic inflammation, much more 



DISPLACEMENTS OF THE UTERUS. 323 

moderate of a uterus in situ. It will not be necessary for me to 
enter into a detailed account of the symptoms that seem to depend 
upon procidentia. They so much resemble those attendant upon 
chronic inflammation and the more moderate displacements, that 
the reader has but to remember, or refer to them, in another part 
of this work. 

The Diagnosis is not generally difficult. Inspection of the 
protrusion is the only way we can be positive in our conclusions. 
We find the urethral orifice external to the arch of the symphy- 
sis, and if a probe or catheter is introduced, it passes down in the 
front side of the tumor instead of backwards and upwards. If we 
pass the finger into the rectum the uterus will not be found in its 
proper place in the pelvis, and the digit can be bent down forward 
over the perineum into the centre of the tumor and there feel the 
fundus. At the lower end of the tumor there is an opening into 
which the probe will enter and pass upwards, in the central line 
of the mass. These marks are distinctive, and are not all pres- 
ent in any known condition beside. 

The Prognosis may be set forth by answering two questions. 
Is it disastrous in its effects ? Is it curable ? Procidentia is not 
fatal in itself, but may so impair the general health of the patient 
as that she may fall an easy prey to intercurrent diseases. The 
amount of suffering resulting from it cannot be told in language, 
but is generally protracted and torturing ; equal to anything else 
to which woman is subject. The second question does not admit 
of a definite answer. It is certainly obstinate under most judi- 
cious treatment, if not in some rare cases entirely incurable. 

The Treatment is founded upon the three indications derived 
from the nature of 'the case. Restore the perineum, remove a 
portion or cause contraction of the hypertrophied vagina, and 
strengthen the relaxed ligaments. My own experience is decid- 
edly favorable to the use of artificial support, and in a great many 
instances it will be practicable and effective. If the uterus can 
be kept in its proper place, the ligaments will contract and be- 
come more resistent, the vagina also diminishes in size, and if the 
perineum is not partially lost it will assume its tone, and relative 
form and position. Such pessaries as may be made to sustain 
the organ without distension or pain are best adapted to the work. 
In fact the vagina ought to be distended as little as possible. They 



324 DISPLACEMENTS OF THE UTERUS. 

should not rest on the perineum for support. Those supported 
externally are most successful when they can be tolerated. It is 
true that we sometimes succeed with globe pessaries, or discs, or 
lever or ring pessaries. When the perineum preserves much of 
its tone these instruments will fill the indications, but not other- 
wise. A stem pessary, with an air-bag globe of small dimensions 
at the upper end of the stem, will be tolerated often and prove, 
very useful. The stem may be planted upon a shield that sets upon 
the external organs outside, and there retained by straps or band- 
ages. This is a better way than to have a stiff rod reaching out 
and up to the top of the pelvis, or even up the abdomen. So long 
a rod under all movements of the body, bears with rigid fixedness 
upon the uterus. To fix the instrument at the vulva with a cord 
or band, places it where it is not subject to every form or great 
latitude of motion, while it does somewhat yield to internal pres- 
sure. The great trouble in the use of these instruments is that 
sometimes, after our best efforts to secure the results, they are not 
tolerated, too much sensitiveness of the parts preventing them from 
being worn. The pessary ought to be worn only when the patient is 
in the erect posture. It should be taken out after lying down and 
reintroduced before rising in the morning. I am sure that patience 
in selecting and modifying the shape of the pessary, with a clear 
view of the indications to be fulfilled, will enable us to succeed per- 
fectly after having made a discouraging number of trials. We should 
study the case, and learn why the instrument is not tolerated, 
and correct the difficulty by changing or correcting the qualities of 
the instrument. It is remarkable how the vagina and perineum 
will contract and become strong, when the uterus is kept in its 
place for some years. I can but think that an ingenious use of 
artificial support will cure as many if not more cases than any 
other one sort of treatment. Astringent injections should be per- 
severingly used in connection with the artificial support. Satu- 
rated or very strong solutions of sul. acid, tannin, acetate of lead, 
&c, and decoctions of astringent bark, as oak, are the most eligible 
and effective forms for them. 

The mode of management and objections to pessaries have been 
considered. But for reasons, all of which it is not necessary or 
possible to mention as applicable to every case, surgical operations 
become preferable. When they succeed, the cure is more quickly 



DISPLACEMENTS OF THE UTERUS. 



325 



accomplished, at least they are more under the control of the 
surgeon than other processes, and do not entail so long an amount 
of perseverance under suffering. 

I beg the reader to remark that surgeons have generally in 
their operations addressed themselves to but one item in the case. 
One party operates upon the perineum, restoring or lengthening 
it, more or less completely to close up the vaginal orifice, while 
another party lessens the diameter of the vagina itself, and con- 
densing its walls into cicatricial or undistensible tissue ; and it is 
feared that the success of one procedure too frequently leads the 

Fig. 24. 




A, cervix uteri ; E. urethra ; C C C C. denuded surface. 

operator to almost indiscriminate repetition of one kind of opera- 
tion, instead of acknowledging the importance of another, and 
the necessity of meeting it with a different sort of surgery. It 



326 



DISPLACEMENTS OF THE UTERUS. 



is not necessary to trace the history of these operations. Two, 
quite different in their nature, have been perfected and practised 
by the two greatest living representatives of female surgery, viz., 
Dr. J. Marion Sims and Mr. I. Baker Brown. Dr. Sims operates 
on the walls of the vagina. His operation consists in removing 

Fie. 25. 




Figure 25, showing the uterus entirely protruded from the external organs. A, urethra; B,os uteri; 
c c c c, the denuded parts with the wire sutures ready to approximate the denuded edges. 

the epithelium of the mucous membrane, so as to denude the latter 
thoroughly, around a triangular space on the anterior wall of the 
vagina. The base of the triangle is at the cervix, and the apex 



DISPLACEMENTS OF THE UTERUS. 327 

near the urethra. It is represented by Fig. 24. Dr. Sims rec- 
ommends this to be done with the uterus returned into the vagina, 
but I cannot understand why the operation may not be more 
easily done with the uterus in its procident state. I have never 
done the operation, but I certainly would denude the membrane 
and insert the silver wires as they are seen in Fig. 25, then re- 
turn the uterus, and afterwards bring the parts in apposition, 
and keep them so by twisting the wires. Dr. Emmet prefers the 
scissors to remove the epithelium to the knife ; he thinks there is 
less bleeding. The patient is prepared for the operation by thor- 
oughly evacuating the bowels the day before, and administer- 
ing, an hour before its commencement, half a grain of morphia. 
Chloroform ought to be given so as to keep the patient uncon- 
scious. Then placing the patient in position on her back, with 
the thighs well separated, the uterus is drawn down so as com- 
pletely to invert the vagina, and held by a tenaculum in the hands 
of an assistant. The surgeon, by means of the scissors and ten- 
aculum, removes the membrane, as represented in Fig. 24. This 
being done and the bleeding having ceased, he may proceed to the 
introduction of the sutures, being careful to cause the needle to enter 
at equal distances from the margin of the cut surface outside of the 
triangle, pass well into the substance of the membrane, and come 
out close to the margin of the cut surface inside of the triangle, 
and in the same manner to dip under the other limb of the tri- 
angle. At the base they should be brought out every quarter 
of an inch in the cut, crossing from the longer limb of the figure. 
Drs. Sims and Emmet pass silk sutures through with the needle, 
and thus bring the wires through by attaching them to the thread. 
After this much of the operation is completed, the patient may be 
turned on the left side, and the vagina distended as for the opera- 
tion for vesico- vaginal fistula, the parts carefully coapted, the upper 
two wires requiring great care to bring the whole of the elongated 
denuded surface together. The rest of the stitches from above down- 
ward may be drawn and twisted so that the denuded surfaces lie 
in even contact. The patient must be kept quiet by opium for ten 
days, the bladder emptied with the catheter every four or six 
hours, to prevent the urine from running on the wound, and the 
vagina should be syringed twice a day, after the third day. Dr. 
Emmet advises us to remove the sutures on the tenth day, but 



328 



DISPLACEMENTS OE THE UTERUS. 



says they may be allowed to remain longer. The sutures should 
be sufficiently numerous — every quarter of an inch — to keep the 
parts thoroughly in contact, and they must be drawn tight enough 
to bring them well together, without strangulating them. For di- 
rection as to twisting the wires, the reader is referred to the re- 
marks, on this subject, in the article on vesico-vaginal fistula. 
They should be cut and arranged after being twisted, as in the 
operation for that accident. This operation is applicable to cases 
where the hypertrophy of the vagina is very great, and the per- 
ineum entire but much distended. 

Mr. I. Baker Brown's operation is applicable to those cases 
where there is deficiency of perineum from laceration. It consists 
in denuding the posterior wall of the vagina an inch above the raphe 
of the perineum, and up the sides of the orifice two-thirds of the 
inner surface. The mucous membrane should be pretty thoroughly 
removed in order to give a solid substance for adhesion, deep 
stitches as for restoration of the ruptured perineum passed, and 
the parts evenly adjusted. Fig. 26 shows the surfaces prepared 
and the sutures inserted. 

Fig. 26. 




Figure 26, showing the parts, c c, denuded and the sutures passed. 

There can be no doubt but that cases might be cured by a com- 
bination of these two operations, where either one alone would 
fail. In such cases, Sims's operation should be done first, and 



DISPLACEMENTS OF THE UTERUS. 329 

after the patient is entirely recovered from it, the deficient peri- 
neum can be restored. 

Retroversion and Retroflexion of the Uterus during Pregnancy. 
— The uterus is sometimes found retroverted or retroflected dur- 
ing pregnancy. When small during the first few weeks of preg- 
nancy, its existence is not observed because it produces no incon- 
venience, and it is not until it grows large enough to partly or 
completely fill up the pelvis, that anything is known of it unless 
discovered by accident. If it is examined at such time, the os 
uteri will be found against the symphysis pubis, sometimes but 
little above the arch, but occasionally as high as the top of that 
junction. If the uterus is retroverted fully, the mouth looks up- 
ward and forward ; if retroflexion exists, the os is still at the sym- 
physis, but its opening is directed downivard and forward. In this 
last case the cervix is bent upon itself at a sharp angle, the lower 
extremity as before remarked looking downward and forward, and 
the uterine extremity turned backward and downward. So that 
the difference in these two conditions consists in the bent state of 
the cervix, and not in the position of the uterus. The body of this 
organ has its axis reversed almost completely, the fundus extremity 
running through the lower bone of the sacrum, while the upper 
extremity of the axial line passes out of the abdomen above the 
symphysis. The body lies in the hollow of the sacrum included 
in the peritoneal cul de sac between the vagina and the rectum. 
Both these canals are compressed, the rectum hard against the 
sacrum and the vagina up against the pelvic bone. The direction 
of the vagina is upward and forward instead of backward, its usual 
course. The finger cannot be made to sink deep into the vagina 
except behind the pubis ; in introducing, it turns upward and for- 
ward. The urethra runs up in close contact with the symphysis 
pubis, and is narrowed very materially by extension and pressure, 
so that it very imperfectly performs the function of a viaduct from 
the bladder. 

Causes. — Although pregnancy usually corrects misplacements 
of the uterus, such is not always the case, for this condition is 
sometimes a mere continuation of its unimpregnated position. It 
is well understood by accoucheurs also, that in the early months 
of pregnancy the normal position of the organ is depression, and 
that prolapse and retroversion are not unusual effects of recent 



330 DISPLACEMENTS OF THE UTERUS. 

impregnation. Under certain circumstances this last deviation is 
not corrected by the advance of growth in the organ. Where 
other causes co-operate, a distended bladder may aid in causing 
the uterus to assume and retain this position, as may also loaded 
intestines pressing upon the fundus and anterior face. These 
causes and perhaps others operate to bring about a gradual dis- 
placement, but there are some that cause the condition suddenly. 
It should be remembered that it is only at a certain time that these 
sudden causes can produce the effect, and that is after the end of 
the third mpnth and before the beginning of the fifth month. It 
is about this time that the uterus attains a bulk sufficient to partly 
or entirely fill up the pelvic cavity. If when it has attained this size 
a sudden impulse is imparted to the fundus and anterior face of 
the organ, the fundus may be crowded so low into the hollow of 
the sacrum as to reverse the axis. In this state the forces acting 
in favor of correction are feeble and may fail to bring it about. 
Strong abdominal pressure upon the intestines and bladder under 
tenesmus, falls upon the feet or breech, lifting heavy weights, 
and even severe sneezing and coughing, are occasionally causa- 
tive. In the cases where the efficient causes are suddenly applied, 
the symptoms are acute and established at once. In the other 
cases the train of symptoms gradually make their appearance. 

Symptoms. — When induced suddenly the patient is seized with 
great pain in the back, with a sense of weight upon the perineum, 
constipation, retention of urine, tenesmus, dragging sensation in 
the loins, and often though not always, sickness of stomach and 
vomiting. If gradually established, the pains, constipation, and 
retention of urine are slowly established, it requiring from seven 
to twenty-one days or more to render them intolerable. I knew 
a case caused by a woman riding all day in railroad cars without 
urinating. 

There are two important symptoms, viz., retention of the urine 
and faeces ; from these result most of the distress complained of. 
Great distension of the bladder and the terrible suffering thereby 
produced is the worst. The student should bear in mind that 
quite frequently this symptom is deceptive. The urine is con- 
stantly dribbling from the meatus, and the patient thinks, and 
will say, she passes plenty of urine. The fact of this constant 
slight discharge should cause us to suspect that the bladder is dis- 



DISPLACEMENTS OF THE UTERUS. 331 

tended ; it does not occur when the bladder is empty ; it is not suf- 
ficient to prevent it from being distended. Indeed I do not now 
recollect any circumstances but over-distension that causes it. 
Retention of feces is not productive of so great trouble as the 
other, but is attended with more or less inconvenience. 

Great pelvic distress with stillicidiUm urince are almost charac- 
teristic of retroflexion or retroversion, when recent pregnancy 
exists. 

Diagnosis. — This is usually not difficult. The first, a very im- 
portant consideration, is the existence of pregnancy. Upon making 
vaginal examination, immediately upon introducing the finger it 
comes in contact with a tumor. The pelvis is filled up by it, in 
the posterior and lower part so that the finger is directed upward 
and forward. Very high up, the vaginal cavity is quite small 
from pressure at its extremity ; in contact with the pubis is the os 
tincce, very firmly held in its place. The tumor is round, elastic 
and smooth ; not so hard as fibrous tumor, more central than 
ovarian, and more uniformly round than extra-uterine pregnancy. 
It may be ascertained in most instances, also, that the tumor is 
larger toward the sacrum than the symphysis. 

Termination. — When left to itself retroversion will terminate 
in abortion, when the contents of the uterus will be expelled and 
the symptoms thus relieved ; or the bladder may be ruptured, the 
urine being discharged in the peritoneal cavity, causing painful 
death ; or the uterus may be ruptured, and its contents discharged 
in the cavity of the peritoneum, giving rise to fatal peritonitis ; or 
the foetus and its membranes may be surrounded by fibrinous ma- 
terial, the patient recover, and these substances remain there en- 
veloped, or, inducing local suppurative inflammation, be discharged 
by exulceration. Sometimes the tenesmus becomes so great as, by 
the violence of the efforts, to break through the posterior walls of 
the vagina and uterus, and discharge the contents through the vulva 
from this artificial opening. Inflammation sometimes arises with- 
out being initiated by any of these disastrous accidents, and less 
suddenly causes the death of the patient. I think there can be 
no doubt but that there are very rarely cases of spontaneous re- 
position, recovery, and completion of the term of gestation. 

The Prognosis is unqualifiedly bad if left to nature, but equally 
favorable if intelligently treated at the proper time. 



332 DISPLACEMENTS OF THE UTERUS. 

Treatment. — The main thing to be done is to replace the uterus. 
This can very generally be accomplished. The attempt should 
not be delayed, as the uterus is constantly increasing in size, and 
the impaction becoming more certainly greater, increasing the 
difficulties as well as dangers. To facilitate the replacement, the 
bladder should be emptied by the catheter when practicable, and 
the faeces removed from the rectum. This takes away some of the 
obstacles. Sometimes the urethra is so tortuous in its course, 
and the walls compressed so completely together, that a catheter 
will not enter the bladder. An elastic catheter will sometimes 
pass the obstruction when the metallic will not ; whichever we 
may use should be urged forward with the utmost gentleness, 
bearing in mind the great danger of perforating the attenuated 
urethra. The patient should be placed upon her knees and chest, 
or on the left side with the left arm behind her, the thighs strongly 
flexed and the right drawn up close to the abdomen and thrown 
forward. She should be placed on a table or the edge of a bed, 
so that the genital organs are easily controlled by the operator. 
In this position we may often succeed in replacement by the hand 
alone. The right hand should be well lubricated, and all the 
fingers be introduced into the vagina, so that the palmar surface 
is turned to the sacrum. The tumor is thus pushed up very gently 
and slowly with the pulps of 'the fingers pressed closely upon the 
face of the sacrum, as high as the hand may be made to reach. 
There are not many cases in which the fingers will fail to carry 
the fundus above the promontory of the sacrum. When thus ele- 
vated, it suddenly starts up and assumes the normal position. If, 
however, the fingers do not reach high enough for this purpose, a 
collapsed gum-elastic bag or bladder, may be carried up between 
the fingers and the uterus, and when elevated as much as we can 
reach, the bag may be inflated sufficiently to raise the uterus high 
enough. I have succeeded in all the cases I have tried with this 
method, and I think when the impaction is not so great as to 
preclude dislodgement that it will almost invariably succeed. 
Some surgeons recommend the introduction of the empty bag into 
the rectum, and inflating it there, and pushing it up ; others intro- 
duce a drumstick, with the end cushioned and lubricated, into the 
rectum, and pressing it against the uterus, elevating it in that way. 
Again, an instrument is used, not unlike two drumsticks, somewhat 



DISPLACEMENTS OF THE UTERUS. 333 

curved, attached together. The attachment confines the ends very 
near each other. The end of one of the branches goes into the 
rectum and the other into the vagina. Thus arranged, they pass 
up and carry before them the uterus. These expedients are very 
sure, but rough and not very safe means of arriving at the results. 
I think as much force in a proper direction can be applied by the 
fingers and elastic bag, as it is judicious to employ in such cases. 
There are other methods of proceeding, but I do not think it nec- 
essary to mention any other, as these will suffice when reduction 
is practicable. 

In all these efforts to elevate the fundus we may fail, and then 
we may evacuate the uterus. This can generally be done by pass- 
ing a bent probe through the mouth of the uterus, far enough 
to rupture the membranes, and permit the escape of the liquor 
amnii. This being done, abortion will soon ensue, I can conscien- 
tiously only mention, for I can hardly think the operation of punc- 
turing the uterus with a trocar through the vaginal wall ever 
commendable or necessary. The cervix is probably hardly ever 
so inaccessible but that some form of bent instrument can be made 
to enter it. 

Inversion of the Uterus. — Inversion is the turning of the uterus 
inside out, with the fundus down and the cervix up, a reversion of 
its surfaces and ends. It is partial or complete. When partial, 
the fundus is depressed in all degrees, from a mere indentation to 
a considerable protrusion through the cervix and os uteri. The 
depression of the fundus, or partial inversion, passes into com- 
plete when the whole organ, fundus, body, and neck, have passed 
through the mouth, and hang down below it. It presents a recent 
and a chronic form. The recent may be regarded as extending 
through the first two weeks ; after which, the circumstances and 
condition of the uterus and patient become what they remain in 
the future, however long it lasts. The uterus, in that time, has 
been condensed by contraction and involution to such an extent as 
to make the case permanent and difficult of change, except to 
diminution and further condensation. Inversion almost invariably 
occurs anterior to or at the time of the removal of the placenta, 
but several hours, and, in very rare cases, several days may elapse 
before it is complete and discovered ; for it is quite probable that 
in these instances partial inversion or greater or less depression of 



334 DISPLACEMENTS OF THE UTERUS. 

the fundus had existed from the time of delivery. It is believed 
by different parties that there are two modes observed in the pro- 
cess of inversion. Sometimes the fundus is indented or depressed 
in the cavity of the body like the bottom of a "junk bottle," the 
depression rapidly or slowly increasing until it is completely down. 
At others, the whole of the fundus, and, more or less, the whole 
of the body, are firmly contracted, while the cervix remains flabby 
and relaxed. In this condition a slight amount of abdominal te- 
nesmus will drive the contracted part down through the relaxed 
cervix; and thus initiated, it requires but a continued action of the 
fibres of the organ and abdominal muscles to finish the process. 
The causes of inversion are not always obvious, as cases have oc- 
curred under circumstances when least expected from any discov- 
erable reasons, and inversion fails to be brought about by circum- 
stances that are usually enumerated as sufficient. We occasion- 
ally meet with instances that have no history, and neither patient 
nor physician can give us a clear idea of the time or manner of 
the occurrence. Such a case was the subject of litigation in this 
city a few years since. And other cases are recorded in virgins, 
and consequently referred to congenital origin. In a large major- 
ity, however, we may trace the history back to accouchement. 
The predisposing causes are enlargements and partial or complete 
passiveness of a part or the whole of the muscular fibres of the 
uterus. These are the conditions in confinement at full term, or 
abortion or premature labor, also enlargement from hydatids, hy- 
drometra, tumors, &c, &c. When the uterus is thus enlarged and 
lax after a greater or less loss of its contents, traction on the cord 
or placenta, or contained tumor, or injudicious or accidental pres- 
sure on the fundus by the hand of some person, or the action of 
the abdominal muscles thrusting the contents of the abdomen 
downward upon that part of the organ, it may be inverted. It 
is possible, I think, also, that powerful, irregular action of the 
fibres of the uterus, may cause the initiation and completion of the 
process of inversion. It is then said to be spontaneous. The 
weight of the placenta, or the contraction to expel a polypus, may 
commence inversion, and even complete it. The irregular contrac- 
tions that result in inversion may commence before the expulsion of 
the child. After the liquor amnii has been discharged for a long 
time, the uterus contracts to suit the inequalities of the foetal sur- 



DISPLACEMENTS OF THE UTERUS. 335 

face ; the globular shape of the organ being replaced by inequali- 
ties in a number of places. Much is yet to be learned on this sub- 
ject. It would seem clear from statistics brought forward by Drs. 
West and McClintock that it is exceedingly rare, if it ever occurs, 
under good management of labor cases. It has not been encoun- 
tered in patients confined in the London Maternity Charity, nor 
the Lying-in Hospital of Dublin in 140,000 cases. The student 
is not to consider from this that it is impossible for it to occur in 
the hands of the ablest of accoucheurs. 

Symptoms. — Usually these are appalling in the extreme. With- 
out warning the patient is seized with faintness, coldness of the 
extremities, sense of great prostration, rapid and very feeble pulse, 
oppression about the heart, copious perspiration, hurried breath- 
ing, often vomiting, ringing in the ears, and blindness. Soon 
these symptoms increase, until the patient lies in a profound state 
of collapse, indifferent to everything transpiring around her, or 
throwing herself in every direction in paroxysms of agony inex- 
pressible. This condition of collapse is not always the result of 
copious hemorrhage, but seems to be of nervous origin. A shock 
not unlike that caused by severe accidents, as falls, strokes, &c. 
But, generally mingled with this sort of impression, there is pro- 
found exhaustion from loss of blood. From this state of collapse 
the patient may very slowly rally, until she enters a tedious and 
imperfect convalescence. Or, in the cases where the exhaustion 
from hemorrhage is added to the great depression of the shock, 
the patient may be overwhelmed, .and in a hour, or very few hours, 
her sufferings end in death. Imperfect recovery from the great 
effects of the first shock may enable the patient to live for several 
days, and at last, in five to ten days, die. In case the patient re- 
covers from the first symptoms, after some weeks she may regain 
a fair degree of health, and retain it or even improve until lacta- 
tion gives place to ovulation, or until this last function supervenes 
upon the first. The first menstrual discharge is preceded by co- 
pious mucous evacuation, and when the menses begin, they are 
more than ordinarily profuse, and generally before they cease 
amount to prostrating hemorrhage. This hemorrhage is repeated 
monthly, more frequently, or is continuous, while the leucorrhoeal 
discharges become very profuse. Functional derangement of other 
and important organs enters the list of morbid impressions : the 



336 DISPLACEMENTS OF THE UTERUS. 

bowels are constipated, the heart palpitates, the stomach cannot 
digest with its former vigor and completeness, the head aches, the 
eyes become weak ; the disposition of the patient changes ; the 
memory fails her ; she is pale, cold, and anaemic ; in short, she 
enters a decadence that is continuous, until, after several months, 
or a few years, she is exhausted and dies. Although this is the 
course usually pursued by cases of inversion, it must be remem- 
bered that there is a class of them in which the patients do not 
suffer even much inconvenience, and their condition is discovered 
only by accident during their life, or on the dissecting-table. 

Diagnosis. — When the symptoms present themselves so as to 
awaken suspicion, the diagnosis of recent cases may be made out 
quite clearly, by the descent of a tumor into or entirely through 
the vagina, and the absence of the uterine globe above the symphysis 
pubis. The diagnosis, after a few days or weeks have elapsed, and 
the case becomes chronic, is not quite so simple and ready. The 
tumor is felt in the vagina, and is more sensitive than polypus. It 
is easily surrounded by the fingers, and by introducing two fingers 
in the vagina to the upper end of the tumor, the depression formed 
by the junction of the vagina and uterus may generally be easily 
surveyed. If this is not entirely satisfactory, the sound should 
be introduced into the vagina before the fingers are withdrawn, 
and, guided by them, be made to sink as deeply into this depres- 
sion as it will go without too much force. If the uterus is inverted, 
the probe will not pass beyond the fingers any distance, but if the 
vaginal tumor be a polypus, the sound will pass up at some point 
some inches above the fingers into the uterine cavity. The opera- 
tor may test .the position of the uterus in another way, by intro- 
ducing the finger high up into the rectum, so that the end may 
reach above the tumor, and retaining it there, he may pass a cath- 
eter or sound into the bladder, and approximate the two : if 
the womb is in place, its thickness will be perceived interposed 
between the two, but if inverted, the extremity of the catheter can 
be brought down upon the finger, with nothing but the membran- 
ous walls of the bladder and rectum intervening. 

Prognosis. — No more serious complication of labor can occur 
than inversion of the uterus. The danger is great and imminent ; 
in a considerable majority of cases proving fatal, the patient dies 
within a few hours. Mr. Crosse says, " In seventy-two out of one 



DISPLACEMENTS OF THE UTERUS. 337 

hundred and nine fatal cases, the patients died within a few hours, 
eight of the remainder within a week, and six more within four 
weeks ; another at five months, the result of an operation which 
had an unsuccessful issue, one died at eight months, three at nine 
months, and the others at various periods of from one to twenty 
years." ( West.) Death in the first place soon after delivery seems 
to be the result of rapid exhaustion of the vital forces by the 
terrible shock to the nervous system and the profuse hemorrhage 
that often complicates it. Death in subsequent times, however 
remote in the chronic form, is brought about by impairment of 
the vital functions by the same means, operating more slowly but 
as surely. The patient dies from exhaustion in both forms. Ac- 
cordingly, we find that while inflammation has something to do in 
affecting the issue in rare instances, those cases in which there is 
no uncommon hemorrhage or leucorrhoeal discharge last longest, 
and sometimes do not prove fatal at all, the patient enjoying fair 
health for many years. I know one patient, fifty-six years of age, 
whose uterus was inverted sixteen years ago, and yet remains in 
that condition, as I have verified by examination, who is in the 
enjoyment of as good health as the majority of women of her time 
of life. 

Treatment. — The management of recent cases will be the easier 
the sooner after the accident it is commenced. Its reduction is 
generally successfully accomplished within the first hour or two if 
intelligently attempted. It is more difficult as time elapses, but it 
should never be considered impracticable until proper and per- 
severing efforts have been made. The first item for consideration 
and action, is to dispose of an attached placenta, when the uterus 
has not detached it before, during, or after its descent. If the pla- 
centa is wholly adherent, its attachment should in nowise be inter- 
fered with until the uterus is returned to its former position, but 
if it is partially detached, it should be immediately separated by 
gently "peeling" it off with the fingers. This instruction has ref- 
erence solely to the prevention or lessening the amount of hem- 
orrhage. If the placenta is attached throughout, the hemor- 
rhage will be trifling ; if partially separated, the condition most 
likely to be accompanied with fatal hemorrhage exists, — relaxation 
of the uterus and partial separation of the placenta. It is well 
known that sufficient contraction of the uterus will separate the 

22 



338 DISPLACEMENTS OF THE UTERUS. 

placenta, and when not contracted enough to do so, it is in too lax 
a state for us to desire its detachment. If the placenta is partially 
separated, the completion of it by the fingers, as in the case when 
included in the uterus, will enable and stimulate this organ to con- 
traction, and thus to the suppression of the hemorrhage. I do 
not think the question of convenience of return, or the possibility 
of being foiled in the reduction by the continued attachment, 
should be entertained. The want of contraction enough to throw 
off the placenta is an evidence of such profound inertia as to in- 
sure easy reduction of the uterus. 

It being decided what course to pursue with the placenta, im- 
mediate efforts should be made to revert. And before beginning 
these efforts, we should remind ourselves of some facts in the case, 
that are apt to be lost sight of in the hurry and confusion of such 
an appalling occasion. One fact is, that immediately after the 
occurrence of the accident, the uterus is in the same flaccid condi- 
tion in which it was incapable of resisting the action of the cause; 
another is, that it soon begins to contract, becomes firm, and, con- 
sequently, more difficult to affect by counter influences ; and a 
third, that the more the uterus is stimulated, by handling or other- 
wise, the sooner and more firm the contraction becomes, and, con- 
sequently, the greater difficulty in reduction. 

No operator has complained to us of the bulk being too great to 
return, but all of the resistance caused by contraction. The expe- 
rience of Dr. Meigs is conclusive on this point. He found that 
upon attempting to reduce the size of the uterus, by squeezing it 
to expel the blood, he caused it to contract, and it became so hard 
as to resist his efforts to push it up within the os ; but as soon as 
he pressed upon the fundus, he would depress it, or rather elevate 
it, until by continuing pressure, he made it ascend first into the 
body, and through it into the neck, and finally up to its proper 
place. Dr. White, of Buffalo, although he did not mention with 
the same distinctness the effects of the two sorts of pressure, was 
enabled, by indenting first and then following up the vantage, 
finally to push the fundus up the same way through the os and body 
of the uterus, after he had in vain tried to reduce it by squeezing, 
&c. Dr. White's case was reduced in this way eight days after 
delivery. And I must be allowed to express the opinion, that it 
increases the difficulties in recent cases of inversion to try to lessen 



DISPLACEMENTS OF THE UTERUS. 339 

the bulk of the uterus. A great bulk indicates a flabby reducible 
state, and is favorable to success, instead of otherwise. Do not 
squeeze the uterus to lessen its size in these cases. 

The two cases I have referred to, of Drs. White and Meigs, so 
intelligently and deliberately observed, and so clearly explained, 
furnish us with more intelligible means of arriving at correct ideas 
of the steps by which inversion of the uterus is reversed, than any 
I am able to find on record. They both concur in showing the 
usefulness of one hand in the vagina to steady the uterus, and di- 
rect the force applied to the fundus by the other hand, and the 
injurious effects of compressing the body of the organ. The most 
appropriate mode of operating in recent inversion, therefore, is to 
introduce the left hand into the vagina behind the uterus, while 
with the fingers of the right the fundus is indented, and gently, 
but steadily and perseveringly, reverted entirely above the os 
and cervix, until it assumes the globular shape, and proper posi- 
tion above the symphysis. If the fingers of the right hand cannot 
be used to advantage, or are too weak to accomplish the desired 
elevation, we may use an instrument resorted to by Dr. White, a 
large elastic rectum bougie, or by Dr. Beers, shaped like the end 
of a walking-cane, with a round smooth head upon a staff. The 
indentation and elevation may be more efficiently effected by this 
latter instrument, perhaps. 

The fact cannot be too forcibly impressed upon our minds, in 
undertaking this operation, that gentle firmness is the proper ex- 
pression for the force to be employed. Perseverance, instead of 
violence, is both more certain, successful, and secure, in over- 
coming the resistance of muscular fibre anywhere. This is espe- 
cially true with the uterus, the strongest muscle in the body. As 
nearly as may be, we should act in the absence of uterine contrac- 
tions. During and after the time we are attempting the return of 
the organ, the strength of the patient must be supported by stimu- 
lants, tonics, and nutrients. Brandy will, perhaps, serve best to 
restore the circulation and heat; it may be aided by the use of the 
aromatic spirits of ammonia, and laudanum. In addition to the 
stimulant and supporting influence which laudanum exerts, it allays 
the irritable condition, so frequently present, of the stomach, the 
uterus, &c. After the urgency of the symptoms has passed by, 
the tinct. of iron, quinia, beef essence, and nutritious diet gener- 



340 DISPLACEMENTS OF THE UTERUS. 

ally, will be necessary to restore the impaired condition of the 
vital energies. The energy with which the stimulants are to be 
urged during the shock, must be regulated by the urgency of the 
danger. Large doses of brandy, laudanum, and spirits of ammonia, 
will not only be borne, but often called for to meet the symptoms. 

The treatment of the chronic form is palliative and curative. 
The palliative is for the purpose, as far as possible, to check the 
drain which is so constantly exhausting the patient, to support the 
system as well as we can, and use any other means suggested by 
the circumstances for the relief of distressing symptoms. 

The hemorrhage is from the mucous membrane of the uterus, 
its outer surface as it lies in the vagina, as also the profuse mucous 
discharge. I think much may be done to moderate, if not stop, 
these evacuations, by astringents introduced into the vagina, so as 
to surround andjie in contact with the uterus. Pledgets of lint, 
saturated with the persul. of iron, passed up into the vagina, and 
allowed to remain on the bleeding surface of the uterus until the 
bleeding ceases, will be of great service. The tinct. ferri chlo. 
on lint is an excellent application for the same purpose. Other 
astringents may be tried in the same manner. If these should 
fail, the vagina may be tamponed fully with cotton dipped in as- 
tringents, or not, as the physician may think best. Severe par- 
oxysms of hemorrhage should be carefully treated in this way 
until they terminate, it being desirable to save as much blood as 
possible. It is not necessary to suggest to the intelligent reader 
the necessity of rest in the horizontal position. Between these 
paroxysms the patient should use astringent injections of concen- 
trated strength, saturated solutions of alum, acetate of lead, tan- 
nin, &c, with a view to condense the mucous membrane, and render 
it less vascular, and in this way abate the urgency of the losses. 
The tinct. ferri chl., one part to four of water, twice or thrice a 
day, will have an efficient astringent effect upon the uterus. When 
the organ extends through the vulva, it is irritated by contact 
with the limbs and clothing and it is very desirable to return it 
into the vagina, and keep it within that cavity. The gum elastic 
air pessary, supported by a T bandage, will keep it in the vagina, 
and may render it more easy of a radical cure, by reduction or re- 
version. I would urge the attendant to personal attention to 
this treatment, to such an extent, at least, as is necessary to have 



DISPLACEMENTS OF THE UTERUS. 341 

it efficiently tried. Very few patients have the intelligence to 
appreciate the importance of it, or to know when proper trial of it 
has been made. 

The radical treatment has for its objects either a restoration of 
the organ or its amputation and removal. So far as we can judge, 
although both operations are attended with danger, that of ampu- 
tation the more. And I think it clearly the duty of the practi- 
tioner, when driven to a choice between the two, to give preference 
to attempts at restoration. We have not only greater safety as an 
argument in favor of it, but successful restoration reinstates the 
patient in all her sexual capacities, while amputation, if not dis- 
astrous in other respects, renders her forever sexually neuter. It 
is to be hoped that before long the operation of amputation will 
be regarded as unjustifiable, because of the certainty of restora- 
tion. Great improvement in our means and the mode of effect- 
ing this must be made, however, before this conclusion can be 
reached. There is no longer room for doubting that restoration of 
the inverted uterus occurs spontaneously. I think it is proven by 
the case of Dr. Hatch, published in Dr. Meigs's Obstetrics. The 
case of Madame Beauchardat, published by Baudelocque, is also, 
I think, conclusive on the point of restoration. Other cases, less 
clearly and circumstantially reported, may be found scattered 
through medical literature for the last century. There are two 
methods, if they may be so denominated, that have been successful 
in reducing chronic inversion of the uterus. Two representative 
cases are published in the American Journal of Medical Sciences 
for July, 1858 ; one by Prof. White, of Buffalo (it was his second 
case), and one by Dr. Tyler Smith, of London. It will be ob- 
served, by examining the reports of these cases, that the restora- 
tion began by the cervix passing through the os uteri first, then 
the body, and finally the fundus. This is different from what I 
think is the common mode of restoration in recent cases. The 
operation for reversion in Dr. White's second case was completed, 
we are led to suppose, in something more than an hour, and at 
one sitting. The uterus had been inverted five months. Dr. 
White operated by introducing the hand into the vagina while the 
patient was in a state of anaesthesia from chloroform, squeezing 
the uterus so as to lessen the size as much as possible, and at the 
same time pressing the organ upwards by means of the large rec- 



342 DISPLACEMENTS OF THE UTERUS. 

turn bougie. Success followed a somewhat protracted manipula- 
tion. The uterus was restored by the lips of the os uteri begin- 
ning to fold outward, and the neck to pass up through this open- 
ing, next the body, and afterwards the fundus. There is nothing 
in this case said about the fundus being indented from beginning 
to end. This is no more than might be expected by considering 
the anatomical circumstances. The fundus and corpus uteri are 
firmer and more solid than the cervix, and hence less likely to 
yield to the same amount of force. The force applied to the fun- 
dus, when the organ is strongly pressed upward, acts more effi- 
ciently upon the cervix than any other part, from the fact that 
the vagina, attached all around the mouth, has not merely the 
effect of resisting the upward pressure of the uterus, but being 
upon the outer surface, it initiates and keeps up the funnel-shape 
expansion of the os necessary to permit the other parts to pass 
through it, as well as to draw it down over the part entering it 
from below. I believe that, in some respects, this is the best man- 
ner of operating for immediate restoration, yet one thing done 
seems to me to be superfluous if not mischievous, viz., the squeez- 
ing the uterus. Dr. Sims recommends that the uterus be supported 
by one hand above the pubis to prevent too great extension upon 
the vagina. While the uterus is being pushed up from below, the 
cup-shaped cavity formed by the inverted cervix may be felt if 
we forcibly press the fingers down into the pelvis from above over 
the pubis. This manipulation affords us valuable aid in forming 
our diagnosis, while it gives the opportunity of assisting in the 
reversion. The great thing to be gained is the commencement. 
After the neck is one-half reverted, the restoration proceeds with 
more rapidity and ease than before, until complete. A better in- 
strument than the bougie used by Dr. White would be a cup on a 
strong handle, large enough to safely lodge the fundus of the 
uterus. I hope I may not be understood as criticizing the opera- 
tion of Dr. White ; on the contrary, I award to him the highest 
praise for his success, and the very lucid manner of tracing the steps 
of the restoration, and delineating the means and manner of doing 
it. His experience has taught the profession one of the most valu- 
able lessons on this subject. Then, as seen now in the light of the 
experience of others, the steps in the operation for immediate res- 
toration are, first to introduce the hand into the vagina, and, em- 



DISPLACEMENTS OF THE UTERUS. 343 

bracing the uterus with it, hold the organ steady, with the fundus 
and cervix nearly parallel with the axis of the superior strait ; 
second, place the fundus of the uterus in the cup of the instru- 
ment held by the other hand, and then press gently upward, in- 
creasing the firmness of it until it is as great as the parts will 
bear without violence, and continuing it with such force until the 
parts yield and pass up. The time required may be considerable, 
and it is an object to continue it for a long time, increasing the 
pressure so slowly as not to be perceived, except by comparing it 
at considerable intervals. The patient should be under the influ- 
ence of chloroform to insensibility, and placed on her back, with 
the limbs widely separated across the bed, and with the hips very 
near it ; or, what would be better, an operating table of convenient 
height about two feet wide and five long. Greater facility would 
be afforded for attendants on such a table. The surgeon should 
kneel or seat himself in front of the patient, so as to have free use 
of both hands and perfect command of the parts. The second 
mode of restoring the inverted uterus, as practised by Dr. Tyler 
Smith, is to apply the force so gradually as to require several days 
for the completion of it. The means used were, first, the fre- 
quent introduction, I think twice a day, of the hand into the 
vagina to squeeze the uterus ; and, second, to keep a gum-elastic 
air-bag distended in the vagina, which constantly pressed the 
fundus upward, certainly, however, with no great force. He suc- 
ceeded in restoring a uterus that had been inverted for fifteen 
years. With proper apparatus I should very much prefer this 
gradual method, as requiring less violence, being less hazardous, 
and perhaps less painful. A small boxwood cup, with a thin air- 
bag in it, to act as a cushion, or cushioned with something else, 
mounted on a strong gum elastic stem, fastened to outside sup- 
port, I think may be made to exert more force upon the fundus, 
and keep it up more continuously than an air-bag in the vagina. 
The amount of pressure should be regulated by the tolerance of 
the patient. The more she can bear the better. By means of the 
cup we may give a better direction to the force used, as well as the 
other advantages. It is but right to inform the reader that I have 
had no experience in either of these modes of restoring the uterus, 
and that these directions are deducible from facts derived from 
others. In attempting this last mode we ought to give the patient 



344 DISPLACEMENTS OF THE UTERUS. 

enough personal attention to assure ourselves that the instrument 
is fulfilling its object. I should not consider that I was gaining 
anything by the introduction of the hand as recommended by Dr. 
Smith, but that I was causing needless irritation and pain. 

As before remarked, it is to be hoped that restoration will be- 
come a practicable thing, almost if not quite always, and hence 
amputation no longer necessary. In the present state of our 
knowledge, however, I think we may regard amputation as prefer- 
able to trusting the recovery of the patient to palliative means 
only. And if restoration is impracticable — but not otherwise — 
and the patient clearly going downward through the different 
grades of chronic exhaustion to final dissolution, we are in duty 
bound to remove the organ. This may be done by the knife or 
ecraseur. The operation is sufficiently simple. By means of 
vulsel forceps the uterus may be drawn down to the vulva, trans- 
fixed in the middle of the cervix with a large needle, armed with 
a double hemp-twine ligature, tied on each side very tightly, and 
then cut through by the knife just below the ligature. Or, without 
the ligature, the chain of the ecraseur may be crushed through 
at the same point. I think amputation by the ligature alone 
entirely unjustifiable, and would prefer the ecraseur. If the 
ecraseur is used, the inexperienced surgeon should bear in mind 
the all-important necessity of not working the instrument too 
rapidly. The chain should not be carried through it under fifteen 
or twenty minutes, resting after each motion of the instrument. 
Hemorrhage is the immediate danger in this operation, and this 
mode of using the ecraseur I think safe. The ligature, when 
the knife is employed, is indispensable to safety. The subsequent 
dangers are peritonitis and toxaemia, which must be treated as 
elsewhere directed. When the uterus is reverted, it is a question 
whether there is danger of, and consequent necessity for precau- 
tions against, the reproduction of the inversion. Although the 
danger is very remote, the patient should be closely watched for 
one or two days to avoid it, and if doubtful symptoms arise, the 
probe or a female catheter should be introduced, and, if need be, 
kept there for two or three days. 



CHAPTER XXV. 

DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. 

The uterus is very much hypertrophied by the processes of ges- 
tation, so that after its contents are expelled by labor, the organ 
weighs from one and a half to two pounds. An atrophizing pro- 
cess, called involution, serves to reduce the organ to its original 
conditions in size and weight. 

Involution is a physiological change, so much so as evolution ; 
but not unfrequently disease invades the tissues, and renders it 
abortive; 1st, causing it to be temporarily "delayed;" 2dly, to 
fall short of completion after it has been commenced ; or, 3dly, to 
proceed entirely beyond the limits compatible with the healthy 
functions of the uterus, reducing it below its usual weight and size. 

I mean by the term " delayed involution," to designate a condi- 
tion of the uterus in which this process does not begin for a num- 
ber of days — from ten to fourteen — after parturition. I think 
this is not very unfrequently the case in a state of disease. 

The generality of physiologists think the contractions which 
immediately succeed and continue after labor, by interrupting the 
circulation in the substance of the uterus, initiate that process, 
and that by the end of a fortnight it is half finished. Should 
these contractions be rendered inefficient, involution is at a stand, 
the uterus remains large, the circulation too great for safety to the 
patient, and sufficient to keep up the nutrition in the muscular 
fibres, which are still capable of a good degree of energetic action. 
For a number of days, the uterus is felt to be as large as a child's 
head above the pubis, and not very firm. 

Causes. — The most common cause of this delay is inflammation 
attacking the substance of the uterine walls. The inflammation 
may be acute, and the patient's suffering such as to demand atten- 
tion, or so slight as to pass without much notice. Cases of puerperal 
metritis, for a week or ten days immediately succeeding delivery, 
not unfrequently prevent this enlarged condition of the organ. 



346 DISEASED DEVIATIONS OF 

Another, cause which probably operates to prevent involution, is 
atony of the uterine muscular fibres. The contractions are feeble, 
and so inefficient, as to delay for a long time, and render very slow, 
the early stages of involution. Too early assumption of the erect 
posture, and undue exercise on foot, keeping the bloodvessels of 
the uterus distended unduly, and thus overcoming the muscular 
contraction, is not unfrequently the cause of delayed involution. 

Symptoms. — The symptoms of delayed involution, separate from 
the inflammation, are not always very well marked. Weight, heat, 
and aching in the back, are the most frequent symptoms we have 
in many cases, especially if inflammation is the cause. There is 
always great danger, however, of a very alarming symptom, 
while this state of the uterus exists, and that is great flooding. 
Where the delayed involution is dependent on atony of the mus- 
cular fibres, hemorrhage is sure to take place if the patient exerts 
herself considerably. Sometimes, as the first indication of any 
seriously wrong condition of the uterus, the patient is suddenly 
seized with copious hemorrhage, which subsides under the influence 
of rest, cold, and astringents, but suddenly and unexpectedly re- 
curs without adequate cause. These recurrent hemorrhages, oc- 
curring in the first fourteen days, are always due, according to my 
observation, to delayed involution. When suspected, the diagnosis 
is not difficult, by an examination with one finger of the right hand, 
per vaginam while with the left hand pressure is made above the 
pubis. The uterus, thus examined, is found to be as large as im- 
mediately after labor is ended. 

The soft uncertain condition of the uterine globe will not always 
enable us to discover it by placing a hand upon the lower part of 
the abdomen alone, but by including the organ between the two, 
there will be no danger of mistake. If the organ retains sufficient 
firmness to be easily distinguished above the pubis by the single 
hand, there will be but little danger of hemorrhage. The local 
distress will then be the only indication of the necessity of a diag- 
nostic examination, when the greatly enlarged condition will be 
easily detected by the examination above directed. The fingers 
maybe easily made to enter the mouth of the organ, and move the 
whole mass, while the hand above will easily recognize the move- 
ment ; or the hand above may be made to press it down upon the 
fingers below. In this way we will easily satisfy ourselves of the 



INVOLUTION OF THE UTERUS. 347 

increased size of the organ. As I have before intimated, in some 
cases the uterine globe is quite firm, in others very flabby. The 
firm condition is a surety against danger from hemorrhage, while 
it is an evidence of inflammation; while the soft state of it indicates 
a strong hemorrhagic tendency. 

Prognosis. — There is imminent danger of serious, if not fatal 
hemorrhage. I have known as many as two cases of sudden fa- 
tality from flooding after the seventh day from the time of labor. 
It is always a serious condition, and should be watched diligently, 
and treated efficiently. Even in cases where the delay is caused 
by acute inflammation, great hemorrhage may take place, although 
not so likely as when caused by muscular atony alone. If the 
delay is for a very considerable length of time, the involution is 
pretty sure not to be completed, but the uterus remains in a state 
of subinvolution for an indefinite time. Very often the causes 
which effect delays continue to act, and finally produce subinvo- 
lution. 

Treatment. — The treatment will depend upon the accompanying 
or causing conditions. If there is inflammation of the uterus, the 
antiphlogistic measures necessary to combat it will be demanded, 
with counter-irritation, fomentations, &c. Should atony, unat- 
tended with inflammation, exist, ergot in large doses will be de- 
manded imperatively until ergotism is brought about. 

I usually give 5ss. pul. secale corn, in infusion every half hour, 
until contractions are brought about. When this is done, the 
effect of the drug may so subside, that it will be necessary to ad- 
minister it again in twelve or twenty-four hours, until all disposi- 
tion to relax has passed away. When the atony and inflammatory 
condition coexist, which may be known by the tenderness, fever, 
and hemorrhage occurring together, the ergot and other treatment 
should be combined. Hemorrhage is not likely to come on until 
after the inflammation is pretty well subsided, in this class of cases, 
and it aids usually in removing the last of it. 

I subjoin two cases as representatives of the two conditions of 
the uterus, and the mode of treating them : 

Case 1st was furnished me by Dr. S. Wickersham of this city. 

He was called to Mrs. E , an Irish woman, aged 28, in her 

fourth labor, May 7th, 1863, 4 o'clock p. M. She had been in 
labor, attended by a midwife, for the most of the day. At 1 



348 DISEASED DEVIATIONS OF 

o'clock A. M. of the 8th pains had entirely ceased, from atony or 
exhaustion of the uterus. Constitutional symptoms began to show 
the necessity for relief. The forceps were used, and the child was 
delivered. The placenta was delivered in due time without diffi- 
culty, and the uterus contracted well. No hemorrhage more than 
usual. The pulse was unusually frequent at and after the time of 
delivery. The labor was followed in two days with puerperal 
fever, in which the uterus and peritoneum were both involved. 
Up to the 20th, she had improved very much, so as to be considered 
by the doctor as convalescent. In the early part of the day, 
sudden and violent hemorrhage prostrated the patient to what was 
at the time considered a moribund condition; but by active stimu- 
lation and external warmth to her cold extremities, she rallied 
very much, and appeared to be slowly recovering. At 6 o'clock 
p. M., on the 24th, the hemorrhage returned with " terrible vio- 
lence," and she was thought again to be dying. Notwithstanding 
the most energetic use of stimulants, she could hardly rally from 
this last attack. On the 26th, in consultation with Dr. Wicker- 
sham, I found the patient so prostrated as to leave but little hope 
of her recovery. Suspecting that the uterus was in a state similar 
to what is found immediately after delivery, I insisted upon making 
an examination, which was resisted by the patient and friends. 
Through the kind perseverance of Dr. Wickersham I was per- 
mitted to do so. The uterus was so flaccid that I could not discover 
it above the pubis until after introducing the finger into the vagina 
and moving it about, when the fundus could be felt as high as the 
umbilicus with the regular globular form. The mouth and cervix 
were large and flabby, and easily admitted two fingers. After this 
examination the indication seemed plain to cause the contraction 
of the uterus. Large doses of ergot were given in addition to the 
stimulating and supporting treatment. Hemorrhage was very 
slight on the morning of the 27th. She continued to improve 
slowly until the 9th of June. At 5 o'clock A. M. the hemorrhage 
returned, and lasted until 10 o'clock a. m., but in so moderate a 
degree as to produce but little effect upon the patient. I was not 
in attendance after the first consultation, and could not trace the 
steps of condensation, but after the 9th of June the hemorrhage 
did not recur. 

It will be seen that on the twelfth day after confinement dan- 



INVOLUTION OF THE UTERUS. 349 

gerous hemorrhage took place ; that it again returned on the six- 
teenth day after delivery to a very alarming extent ; and that 
after the liberal use of ergot the hemorrhage returned but slightly. 
It should be noted, also, that the cessation of the hemorrhage was 
sudden, and probably resulted from faintness, and that it returned 
so soon as the arterial reaction amounted to any considerable power. 
The faintness, doubtless, was the cause of stoppage in both the ter- 
rible attacks before ergot was given, but the hemorrhage was effec- 
tually checked by contractions, the effect of the ergot. 

Case 2d. Mrs. E is the mother of nine children. She is 

33 years of age, and a German Jewess. Of robust, almost ath- 
letic make and habits, she always enjoys excellent health. In the 
last three confinements she has almost lost her life from loss of 
blood both before and after the delivery of the placenta. I at- 
tended her in the eighth labor, the last before this one. There was 
nothing peculiar in it until after the child was delivered, the labor 
having lasted but about four hours. The pains were ordinarily 
vigorous and propulsive. The liquor amnii was not evacuated until 
ten minutes before the head was distending the labia. After the 
child was expelled the uterus did not contract thoroughly. It 
seemed large and rather soft. This state lasted for half an hour, 
when a feeble contraction detached but did not expel the placenta. 
From this time hemorrhage became excessive. I waited for half 
an hour, — using friction, kneading, and pressure over the uterus, 
with application of ice to the vulva, — for contraction of the uterus 
and expulsion of the placenta, but although there were occasional 
pains, they were so feeble as to produce no effect upon the hemor- 
rhage. About this time the ergot I had sent for arrived, and I 
gave immediately 5ss. in a little wine and water. Fearing the pros- 
tration which was rapidly coming over the patient, I introduced 
my hand into the uterus, grasped the placenta, and irritated the 
organ by moving the whole around in it. This brought on con- 
tractions enough to expel my hand and placenta, and deluge the 
bed with coagula and fluid blood. Very soon the ergot began to 
act, and the hemorrhage ceased. I give this description of her 
eighth labor to show her predisposition to inertia uterina. As the 
ninth labor approached, I determined I would administer the ergot 
as soon as the parts were well dilated, and the head began to pass 
the os uteri. I was sent for at 8 o'clock p. M., June 30th, 1864, 



350 DISEASED DEVIATIONS OF 

to attend her. I found the pains active and the os uteri fully di- 
lated, and the membranes distending the labia. I at once gave 
her ergot 5ss. in infusion, making her swallow the ergot as well as 
the water. This was repeated in half an hour. By this time ergot- 
ism was fairly established. In three-quarters of an hour from the 
time I arrived the child was born, and in a few minutes the pla- 
centa was expelled from the uterus into the vagina whence it was 
removed. No hemorrhage followed. The uterus was well con- 
tracted. I considered her condition very favorable, and at the 
end of another hour took my leave. Her condition for the first 
forty-eight hours was in no respect unusual, except that the lochial 
discharge was rather free. From this time I saw but little of her 
until the 10th of July. I returned from the country at 5 o'clock 
p. M., and found she had been flooding since early in the morning 
not very greatly, but sufficient to begin to produce faintness. 
The uterus could be felt above the symphysis pubis as large as a 
child's head, and not very hard. I ordered cold to the pubis, and 
twenty drops aromatic sul. acid in some water every four hours, 
expecting soon to have the hemorrhage checked ; but to my sur- 
prise, at 8 o'clock on the 11th, the hemorrhage still continued, 
being but slightly moderated by the means used. I now ordered 
two teaspoonfuls of vin. ergoti every half hour until the hemor- 
rhage ceased. But the nurse said that the "second dose put her 
in so much pain and caused such large clots of blood to come from 
her that she dare not give it again." The hemorrhage ceased en- 
tirely from this time until the afternoon of the 13th, when it re- 
turned w r ith considerable violence. The ergot was again given, 
and from this time forward the patient had a favorable convales- 
cence, and is now in the enjoyment of good health. 

/Subinvolution is the condition in which involution commences 
and proceeds to a certain extent, and then is arrested, and thus 
leaves the uterus larger than it ought to be, the organ being more 
vascular and heavier. There is quite a difference in the degree of 
subinvolution : sometimes the organ remains three, four, or even 
five inches long, and proportionally broad, while in other instances 
it is scarcely over the natural size. 

Causes. — The most common cause of subinvolution is inflamma- 
tion supervening during the time the process of involution is in 
progress. Often the inflammation commences immediately after 



INVOLUTION OF THE UTERUS. 351 

delivery, and involution proceeds very slowly and with great diffi- 
culty, until, finally, it ceases before being completed ; but other 
times the inflammation commences during the process, probably 
on account of exposure, or prematurely rising from the bed and 
resuming usual exercise. On account of the increased vascularity 
of the organ, its greater size and weight, there are almost always 
more than ordinary sanguineous discharges at the menstrual 
periods, and sometimes even between them. Superadded to these 
we may, and often do have an extensive array of the local and 
sympathetic symptoms of chronic inflammation of the uterus, for 
which I will refer the reader to the subject of inflammation. The 
diagnosis of subinvolution is not difficult. By embracing the ute- 
rus between the fingers of the left hand above the symphysis, and 
those of the right within the vagina, the size will be found in- 
creased ; we may also ascertain by introducing the sound that it 
is larger than usual. But inflammation may sometimes increase 
the size of the uterus in virgin females, so that it will present the 
same symptoms and answer to the same measurement with the 
sound and fingers. And while the diagnosis between subinvolu- 
tion with inflammation, and inflammation with tumefaction of the 
uterus, is a matter of no practical importance, I think the distinc- 
tion may generally be made. In cases of subinvolution the uterus 
partakes more of the shape of the recently impregnated organ. 
It is thicker antero-posteriorly and from side to side, than when 
tumefied by inflammation. In inflammation it is apt to be pro- 
portionably longer than broad and thick. The neck is narrow and 
long in the last, and broad and comparatively thick and short in 
the first state. 

But I have found that these cases are curable by the same 
means that, remove inflammation. Remove the inflammation, and 
the involution is spontaneously completed. If attended with 
symptoms of acute inflammation, antiphlogistic treatment at first 
is demanded ; but should the symptoms be chronic, nitrate of sil- 
ver, bathing, injections, alteratives, tonics, and laxatives, as rec- 
ommended elsewhere for chronic inflammation in this work, are 
indicated and will pretty surely succeed. 

Hypeynnvolution is the state of the organ where the involution 
has proceeded to such a degree as to condense the tissues beyond 
their ordinary density. The condensation thus accomplished ren- 



352 DISEASED DEVIATIONS OF 

ders it less vascular and erectile, and the fibrous structure is paler 
and harder than natural. As the result of this condensation and 
diminution in the quantity of the circulation, the uterus as a 
whole is smaller and lighter than common. The degree to which 
hyperin volution may be carried varies greatly ; sometimes it is so 
slight as to require great care to distinguish it, at another the 
uterus is reduced to half its ordinary weight and dimensions. 

Causes. — Inflammation seems here to be more concerned in the 
production of hyperinvolution than any other morbid process. 
From examinations during the progressive steps of morbid states 
of involution, I am inclined to think that in cases where inflamma- 
tion of the mucous structures exists exclusively, or where inflam- 
mation of the mucous membrane preponderates, the involution is 
arrested, and hence we have subinvolution ; but when the inflam- 
mation is mostly confined to the submucous tissue it proceeds to 
hyperinvolution. 

Symptoms. — The condensation of the tissue and reduction of the 
vascularity of the organ always diminish the menstrual flow ; and 
hence we have decreased menstruation in a moderate degree, and 
obstinate amenorrhea in the more extreme condition. The symp- 
toms attendant upon hyperinvolution are very similar to those 
enumerated in the description of chronic inflammation. They are 
sometimes very distressing, rendering the patient thoroughly 
miserable for many years. The worst cases of this form of dis- 
eased involution I have met with have been traced to inflammation 
resulting from abortions. But it likewise takes place as the effect 
of inflammation after ordinary or full term parturition. 

The diagnosis is easy with the aid of the uterine sound. This 
instrument will not enter the uterus as far as it does into a healthy 
organ. The uterus is lighter and more easily moved, also, by the 
finger introduced into the vagina. 

One of the almost invariable effects of hyperinvolution is ste- 
rility. I have met with a number of cases of sterility occurring 
soon after marriage, on account of abortion, in the first three or 
four months, being followed by inflammation and hyperinvolution: 
the patient ever afterwards remaining sterile. 

The successful treatment of these cases requires a great deal of 
patience and well-adapted measures. If the change in the condi- 
tion of the uterus is slight, we may sometimes succeed by intro- 



INVOLUTION OF THE UTERUS. 353 

ducing a bougie of slippery elm bark, large enough to distend the 
cavity of the cervix as much as practicable, three or four days 
before the expected menstrual discharge. This seldom fails to in- 
crease the discharge, and if used perseveringly for several months, 
will sometimes cure the case. The bougie should be cut out of the 
bark so as to be about an inch and three-quarters long, for cases 
of moderate contraction, and secured by a thread, and then intro- 
duced. It should be allowed to remain until the discharge begins, 
and then removed. If, however, it is of long standing, and the 
diminution in size very considerable, we will be under the neces- 
sity of using the intra-uterine pessary recommended by Prof. 
Simpson. It may be made of zinc and copper, in order to galvan- 
ize the parts. A description of an apparatus quite appropriate 
to the purpose, will be found on page 82, on the subject of amen- 
orrhea. The only thing I need say in reference to thd- instrument 
here is, that the size will have to be adapted to the degree of ab- 
erration in each individual case. In extreme cases, the instru- 
ment must be small, and after wearing it for one or two months, 
a slightly larger one should be introduced ; and again, after another 
lapse of time, it should be replaced by a still larger one. These 
instruments, sometimes, cannot be borne for a great length of time ; 
when this is the case, they may be introduced just before the men- 
strual period, say from four or five days, and then withdrawn when 
the discharge is freely established. We meet with instances which 
it is necessary to patiently treat in this way for years, and yet 
succeed in making a cure. Perseverance is an invaluable quality 
in treating all the chronic diseases of the uterus, and in none will 
our patience be taxed to a greater degree than in this. 



23 



CHAPTER XXVI. 

CANCEK OE THE UTEKUS. 

" Those growths may be termed cancerous which destroy the 
natural structure of all the tissues, which are constitutional from 
their very commencement, or become so in the natural process of 
their development, and which, when once they have infected the 
constitution, if extirpated, invariably return, and conduct the per- 
son who is affected by them to inevitable destruction." (Miller, 
as quoted by West.) 

This general definition of cancer will include all its varieties, 
which are usually divided into four : 1st. Medullary ; 2dly. Epi- 
thelial ; 3dly. Colloid; 4thly. Scirrhus. I have mentioned these 
varieties in the order of frequency in which they usually occur in 
the uterine tissues. It will not be thought strange for me to say, 
that I have not seen either a case of colloid or scirrhus in the 
uterus. There can be little doubt, however, that both are rarely 
met with. The medullary variety is by far the most common 
form with which this organ is affected, the epithelial being also 
quite common. Cancer of the uterus is of very frequent occur- 
rence, and the deaths from it, compared to death from the same 
disease occurring elsewhere in women, predominate over all other 
localities. It invades the cervical portion of the uterus more fre- 
quently than all other parts of the organ, yet it begins in every 
other portion ; for instance, in the fundus, body, or cavities of the 
body, or in the cervix. In some rare instances it runs its course 
to fatal results without involving all these parts. When it begins 
in the cervix, it usually, either gradually or suddenly, passes up- 
ward to the fundus ; or if beginning in the fundus, or body, it 
creeps downward to the os tinea. I have seen two instances where 
the lower portion of the cervix was but slightly, if at all, changed, 
while all the other parts of the organ were infiltrated by cancer- 
ous deposit. The material of cancer, particularly the medullary, 
is deposited in the tissues, supplanting them more or less perfectly. 



CAXCER OF THE UTERUS. 355 

This is so completely the case, that even the vascular tissue is sup- 
planted. I think the obliteration of the vessels by the intruding 
deposit, thus destroying the nutrition of the tissues, is what pro- 
duces the numerous sloughs, which commingle with the discharges, 
and give them their peculiar odor. 

The epithelial appears to engraft itself upon certain points of 
tissues, and generally springs forward into fungi. It seems to 
cause, indeed, an exaggeration of the vascular tissue at first ; and 
in the beginning, its tendency is self-isolation instead of diffusion. 
This is only the case in the beginning, for after it has lasted for a 
time, the adjacent structures become changed, and more or less 
true cancerous deposit may be found. But at no time is it so 
rapidly destructive as the medullary variety. 

The tissue most commonly attacked by all the varieties except 
the epithelial is the fibrous or fibro-cellular substance. The mucous 
is not frequently attacked but by the epithelial variety. When 
the submucous tissues are the parts attacked, they are thickened 
and indurated, the thickening and induration being very irregular 
in shape and size. The enlargement and induration of cancer 
differ from^ these conditions caused by inflammatory effusion, by 
being always uneven, to such an extent as to distort the organ. If 
one of the lips of the os uteri is hardened from cancerous deposit, 
the elevated points are sharp and angular, and the hardened parts 
terminate abruptly, and in a manner unlike the induration from 
any other cause. The hardening from inflammatory fibrinous de- 
posit is more globular than angular, and less abrupt in its termi- 
nation in the sound parts. If one lip is the subject, it is swollen 
so as to develop it as a whole generally instead of one of its edges. 
The induration terminates by fading away, as it were, into the 
surrounding parts. If the cancerous deposit is in the body or 
side on any part of the wall, it is enlarged into an irregular shape 
and there are pits and points in several places. If enlarged by 
fibrinous deposit, there is not more than one point, and it is or- 
dinarily round, and apt to occupy as one even lump the whole of 
the wall of the side or posterior surface. The epithelial variety 
enlarges the whole organ somewhat equally, apparently by an 
increased development of the vascular system and general tissues 
of the organ. The epithelial most frequently sprouts out into a 



356 CANCER OF THE UTERUS. 

tumor that enlarges, persists, sloughs, and is reproduced with great 
rapidity. 

In the fibrous or fibro-cellular tissue, the infiltration and indu- 
ration increase for an uncertain length of time, until, perhaps, the 
cancerous deposit so far displaces and replaces the ordinary tis- 
sues, that the nutrition of the parts is disturbed by the destruc- 
tion of the bloodvessels, and sloughing takes place over a small or 
large space, owing to circumstances, but always over an irregular 
space, thus leaving a greater or less chasm. This is ulceration, — 
cancerous ulceration. The absorbents do not remove the parts, 
and thus cause ulceration, but there is sloughing and denudation 
by death of many minute parts, the absorbents having but little 
to do in the process. The sloughing causes the smell and putri- 
laginous character of the discharges. This process widens and 
deepens the chasm, sometimes quite rapidly, at others very slowly. 
As I have before observed, in the epithelial or fungous variety the 
sloughing and reproduction are constantly going on, the one com- 
pensating for the other, so that there is not much, if any, perma- 
nent diminution in the parts upon which it is seated. The medul- 
lary variety, on the other hand, removes more or less of the organ 
involved. In the case of the medullary variety, after induration 
and enlargement have fairly begun to advance in the uterus, the 
nutrition of the surrounding organs and tissues is disturbed, and 
the deposit is infiltrated into all the surrounding parts, — the blad- 
der, the rectum, the areolar tissue by the side of the uterus, the 
peritoneum, in fact, into everything in the neighborhood. This 
general deposit is not limited by the coverings or divisions of the 
parts, but all become united, so that the whole pelvic tissues become 
one agglomerated mass of cancer ; or, if it take one direction, the 
bladder and uterus may be glued together, or the rectum may be 
bound thus to the uterus. This disposition of the deposit very 
soon becomes sufficient to fix the uterus immovably in its place. 
In the epithelial outgrowths the most of the Changes for a long 
time, comparatively, from the beginning of the disease, is the 
crowding upon the surrounding parts. The serous membrane cov- 
ering the organs ordinarily resists these changes longer than any 
other tissues, and sometimes may be dissected out from among the 
wreck of tissues quite intact. It does, however, after a while, 
undergo sloughing, if not cancerous change. 



CANCER OF THE UTERUS. 357 

After the ulcerative process has fairly begun, it advances more 
or less rapidly, until much of the surrounding parts is destroyed ; 
the bladder and uterus become one continuous cavity, and sooner 
or later the rectum also is laid open, and then the pelvic viscera 
are involved in one confused excavation, from which the putrilage 
of cancerous degeneration is poured out, commingled with urine, 
feeces, and menstrual fluid. 

I have observed that there is some proportion between the ra- 
pidity of the destructive progress of cancer and the age of the 
patient. It is slower in the aged, and destroys the young patient 
most readily. Of three cases in which cancerous deposit began in 
the body or fundus of the uterus instead of the neck, two were in 
patients beyond the climacteric period, one being sixty-four years 
of age and the other fifty-seven when the symptoms first attracted 
their attention. The other patient was forty-three. In this last 
patient, simultaneously with the evidence of deposit in the body 
of the uterus, signs of it appeared in the bladder, vagina, and clit- 
oris, in the pelvis and the duodenum, and in the pyloric orifice of 
the stomach. From these and other facts in my possession, I am 
inclined not only to look for a more rapid degeneration of the tis- 
sues invaded by cancer in comparatively young patients, but to 
expect that when the deposit does occur in the body or fundus of 
the uterus, it is more likely to do so in the aged. 

The morbid and microscopic anatomy of cancer of the uterus 
do not differ from the disease elsewhere, and as my design is to 
furnish a guide to students of as practical a character as possible 
in an economical space, I will refer them to Walsh, Bennett, Roki- 
tansky, and other authors who have treated on the subject, for par- 
ticulars respecting it. 

Symptoms. — Discharges, pain, and fcetor are the symptoms that 
usually attract our attention in cases of cancer of the uterus. 
When a patient complains of any of these, however, the case is 
generally an advanced one. . Pain, perhaps, is the symptom first 
experienced, and is caused earlier than any other. Unfortunately, 
pain is so common to women, they suffer so often in the region of 
the uterus and hips, that this symptom is not heeded by them until 
some other symptom makes its appearance. The pain is not gener- 
ally intense nor troublesome until the disease is recognized. Nor 
is it peculiar. It is described as lancinating, darting, twinging, 



358 CANCER OF THE UTERUS. 

and very correctly, too, but there is often nothing of this kind of 
pain during the whole course of uterine cancer. And I think I 
express the truth in saying that cancer is almost the least painful 
of all the diseases of the uterus. There is less local suffering in 
cancer than in inflammation and ordinary ulceration, until ulcera- 
tion and discharge denote its fully developed condition. Yet there 
is generally pain in all the stages of cancer, and it is very proper 
to place it among the symptoms ; and the pain is generally dart- 
ing, twinging, recurring at irregular intervals, darting from one 
part of the pelvic portion of the body to another, but not, I think, 
very severe. 

The discharges in cancer are of three sorts, and the mixture 
of these sorts in different proportions. They are, 1st, blood ; 
2d, limpid serum ; 3d, sloughs, generally minute. The first two 
are not offensive to the smell when pure or mixed together, as 
they often are, and they only become so by being mingled with 
the last, dissolving or holding in suspension, or being merely 
mixed with greater or less pieces of dead tissue. In the earlier 
stages of cancer the blood or serum may be and generally is 
effused, while the latter is reserved to the open or ulcerated stage. 
In this open or ulcerated stage all three kinds of discharges are 
almost always mixed together. In women who are still menstru- 
ating, the discharge first experienced is of blood. There is, at 
first, an increase in the amount of menstrual discharge ; a little 
later, and blood is lost between the times of menstruation. The 
blood thus lost is derived from the same source as the men- 
strual blood, — the vessels of the mucous membrane of the corpus 
uteri. Later, when hemorrhage is so constant and attended with 
foetor, it is effused from eroded vessels upon the ulcerated surface. 

The blood in the former case, is produced as the result of con- 
stant turgescence ; in the latter, on account of the disintegration 
of tissue. Limpid, unoffensive serum is almost always observed 
in the cases of old women, after the menstrual period of life has 
passed, and generally coming from the os uteri, which may be for 
a long time unchanged, indicating that it comes from some dis- 
tance up in the organ. In fact, if the same serum was effused 
from the surface of the vaginal portion of the cervix, it would 
most likely be mixed with blood, because the parts producing it 
would not be sufficiently protected to insure the integrity of such 



CANCER OF THE UTERUS. 359 

frail tissue. In two remarkable instances the copious discharge 
of this limpid serum was for many months the only sign of dis- 
ease presented by the patients. One of my patients, sixty-one 
years old, had been under the necessity of wearing napkins for 
six or more months before calling my attention to her condition. 
The discharge was so copious, when I saw her for the first time, 
that I collected about two drachms from the speculum in ten 
minutes. When examined, it was found to resemble distilled 
water in appearance, it was so clear and colorless. There was no 
smell, nor other offensive quality to it. When examined by the 
microscope, no solid substances were found except a very few natu- 
ral epithelial scales. In a very gradual manner this transparent 
liquid became colored with blood. It was sometimes clear and 
sometimes bloody, for several months before becoming foetid, and 
only for a few weeks before the patient died was it constantly 
bloody and foetid. The cervix uteri, in this case, was not attacked 
at all, and the mouth and lips of the neck were natural. The 
body of the uterus, as high as the fundus, was enlarged more than 
double its natural size, indurated and nodulated ; and when ex- 
amined after death, the walls presented the peculiar fibrous hard- 
ness of cancer, but there was no excrescence in the cavity, as I 
had expected to find. 

Whether the discharge is blood or serum, at first, or a mixture 
of both, it is generally odorless ; but after a time it becomes 
foetid, and remains so persistently. The foetor appears, from 
the testimony of most observers, to be peculiar : but I have not 
been able to distinguish it from the smell of putrilage of other 
productions. Perhaps it is for the want of a sufficiently acute 
olfactory. I have no doubt that the smell is caused by the minute, 
numerous sloughs, constantly detached, and undergoing decompo- 
sition in the fluid. When all these symptoms unite, they form a 
case almost unmistakable. Lancinating pain, sero-sanguineous 
discharge, and peculiar foetor, continuing persistently for days and 
weeks, are almost distinctive of cancer. 

I cannot lay much stress on either one of these symptoms ; but 
of the three, the most importance should be attached to the foetor. 
Persisting for weeks, if not traceable to the decomposition of an 
ovum — and this is exceedingly rare — it should at least cause us to 
suspect a cancer. Contemporaneous with the complete establish- 



360 CANCER OF THE UTERUS. 

merit of these symptoms we have constitutional suffering. It is 
not often, I think, that general suffering precedes the local symp- 
toms of cancer, and it has always seemed to me to follow as the 
effect of local disease. It has not been my lot to meet with the 
broken-down constitution sometimes said to be generated by the 
cancerous diathesis. Cancerous anaemia, causing the straw-colored 
translucency of the skin, considered characteristic of the malig- 
nant cachexia, is not distinguishable from the hemorrhagic anaemia 
occurring sometimes in persons of the same age, produced by the 
drain upon the blood. I make these statements just as the facts 
strike me, and leave them with a scrutinizing profession to adopt 
or reject. 

In the fully developed condition of carcinoma the constitution 
suffers, and the collection of symptoms are such as arise from the 
embarrassment and failure of the functions in a long struggle 
with pain, loss of blood, anxiety, and inaction. Debility, with in- 
digestion, palpitations, restlessness, neuralgia, constipation at first, 
colliquative diarrhoea and aphthae toward the end, night-sweats, 
wandering of mind, unsteadiness of purpose, succeeded by delirium 
and apathy ; in fact, all the train of symptoms which precede dis- 
solution, when it approaches through protracted struggles, in which 
pain and exhausting discharges are the destroying agencies. 

Causes. — But little can be said profitably as to the causes of 
cancer of the uterus. The general opinion that it is hereditary in 
most cases is doubtless true; and yet a great many instances occur 
that cannot be traced to such a cause. This is no reason why they 
may not be hereditary ; because sometimes the circumstances which 
permit the hereditary taint to show itself do not exist for a number 
of generations. And, again, the taint may be so dilute'as to require 
very favorable circumstances or co-operating causes to bring it 
out. If a mother dies of cancer at the age of forty-five, and im- 
part the same morbid tendency to her daughters, the laws of cell- 
development would bring it about at the same age in the child. 
If, therefore, the daughter dies a year too soon of some other dis- 
ease, the taint is inoperative though present. Two or three gene- 
rations of cancer-bearing persons, cut off by other diseases, lose 
the history of its inheritance. Or if a mother be the subject of 
cancer at the end of a life of active, nay excessive childbearing, 
while her daughter leads a life of celibacy, or has but a single 



CANCER OF THE UTERUS. 361 

child, the physiological life of the two is so different that we 
would naturally expect some modification of consecutive cell- 
development to result. So that although the hereditary taint is 
the same in the two, their pathological ages may differ, and the 
daughter may not have cancer until a later period, and die before 
that time arrives. We should, I think, allow much for influences 
that may modify hereditary taints, and only regard them as he- 
reditary tendencies, to be brought out in mother and daughter 
under similar circumstances, and which may be postponed, or pro- 
duced earlier in the one or the other by certain conditions. We 
will see good reason for these remarks by examining the circum- 
stances under which cancer of the uterus most frequently occurs. 
Married women are affected more frequently than the single, and 
the fruitful than the barren. When we consider how many more 
married than single women there are in civilized communities, and 
how few married women are sterile, we may not be able to attach 
much importance to these facts. A much more significant fact 
is that a very large majority occur during the menstrual years of 
a woman's life. It is true that there may be nothing more than 
a mere coincidence in these facts, and that, after all, the heredi- 
tary mutations in the system during these years may bring about 
cancerous deposit, independently of any connection with the men- 
strual function. But it certainly is a coincidence, if not an etio- 
logical coincidence. As to the connection of cancer with chronic 
inflammation and ulceration of the uterus, much has been and 
may be said. I cannot lay my hand on statistics upon this sub- 
ject, but I have never observed the coincidence of inflammation 
and cancer, or cancer to be a consequence of inflammation. I 
am aware that this statement amounts to very little ; but I wish to 
record it as the result of my observation up to this time. It is 
unnecessary to point out causes of fallacy in former years, and 
appeal to more correct observers to settle this question. How- 
ever, if they may be occasionally connected, there are but few at 
the present day who believe cancer to be the result of long-con- 
tinued inflammation. 

Diagnosis. — It would seem that the diagnosis of a disease so 
marked as cancer would be an easy matter, and so it is when all 
or even most of the peculiarities of the disease have been fully de- 
veloped ; but in the very beginning there may be much obscurity. 



362 CANCER OF THE UTERUS. 

A patient complaining of nothing more than a perfectly clear, in- 
odorous, watery discharge, seemingly in the enjoyment of good 
health, would hardly be regarded as a victim to one of the most 
surely fatal and loathsome diseases incident to the human race ; 
and yet, it is almost invariably so, when the patient is advanced 
beyond the epoch allotted to menstruation. The cancerous disease, 
as it usually occurs, advances beyond the period of doubtful symp- 
toms in a very short time, and in the majority of cases our. attend- 
ance is not requested until a scrutinizing examination will enable 
us to decide very positively on the nature of the case. There is 
such a clear, concise, and yet thorough array of diagnostic particu- 
lars on pp. 217-18, presented in a manner to make it easy of refer- 
ence, that I should trespass on the time of the reader by repetition. 
It would not make it clearer, hence, I shall merely refer to them. 
Our attention will be attracted by the unusual amount and char- 
acter of discharge, pain, and smell. Then by a physical exami- 
nation, guided by the tabular view there given, we will not be 
easily deceived. 

Prognosis. — The prognosis of cancer is a gloomy one. Indeed, 
there is no disease that so uniformly terminates fatally as can- 
cer of the uterus. Notwithstanding this fact forces itself upon 
our observation, there will sometimes, in the course of a large ob- 
servation, occur a recovery from it spontaneously and unexpect- 
edly. In ordinary medullary cancer there is less hope than in the 
variety called epithelial. I need not enter into the discussion of 
the causes of this fatality. Whether the disease is essentially a 
blood-disease, or whether primarily local, there are but few in- 
stances in which it is not multilocular. It exists from the begin- 
ning, or very soon afterwards, in more than one place. Yet again, 
this is not invariably the case. We very seldom meet with an in- 
stance in which the area of deposit is small and confined to one 
locality. If this locality is accessible, the case probably is cura- 
ble. I say probably, because the pathology is treacherous, and 
we cannot be positive. This gloomy picture is in part relieved by 
the greatly improved palliative means we now possess. Very 
much may be done to allay the agonizing state of body and mind 
under its ravages. 

The epithelial form is not quite so fatal. It is also a very fatal 
form of disease, but it is now generally admitted that it is local 



CANCER OF THE UTERUS. 363 

in its existence, and that it never becomes otherwise except by 
travelling along contiguous tissue. If in the cervix, and particu- 
larly if in the lower extremity of the cervix, it may possibly be 
cured. As a drawback upon the favorable consideration here 
suggested, it should be said that it is not often confined to the 
vaginal cervix, but when we are called upon to treat it, it extends 
entirely beyond our reach. 

The treatment is mostly palliative and but slightly curative. 
The only curative means we possess are surgical. No medicine 
can be relied upon to eradicate the disease from the system, al- 
though very many have temporarily enjoyed the reputation of 
doing so. The most that medicine can do is to defend the patient 
against its rapidly prostrating influence, and palliating the suffer- 
ings connected with it. 

Propositions for extirpating the whole uterus have been fol- 
lowed out, we are told, but I need not say are regarded now as 
utterly unjustifiable. The operation of amputating the vaginal 
cervix is now regarded, however, as demanded under certain cir- 
cumstances of cancroid and even cancerous disease. If the dis- 
ease is clearly confined to this portion of the uterus, and the pa- 
tient in a fair condition of general health, we may with propriety 
recommend and perform the operation. The operation is not a 
difficult one or necessarily very dangerous. The cervix should 
be drawn down to the external organs, so as to be fairly exposed 
to view, encircled by the chain of an ecraseur, and crushed off. 
This is but the work of a few moments by a skilful surgeon. The 
cervix may be drawn down by two vulsel forceps, and held in place 
by an assistant, while the operator uses the ecraseur. The 
dangers to be apprehended in performing the operating are the 
wounding of the bladder in front, or the peritoneum behind, and 
of leaving a portion of the disease. The dangerous consequences 
of a proper operation are shock and hemorrhage. 

If these do not occur, the patient will usually rally, and recover 
from the effects of the operation. Inflammation remains to be 
mentioned as a consequence that may prove fatal also. 

The actual cautery is recommended as very favorably modifying 
the ulcer of uterine cancer, and was thought to have afforded a 
prospect of cure in some instances. I have not had any observa- 
tion in the use of it, and consequently, will not express an opinion 



364 CANCER OF THE UTERUS. 

upon its merits. Dr. West speaks very favorably of it in certain 
cases. I have used caustic potassa, but have not gained any good 
results from it, and do not now think of applying it to this disease. 
The cases in which these surgical means promise hope are very few, 
and their success is effected in but a moiety of these. 

Palliation of the pain, smell, and debility, is the object of the 
most of our treatment. We use local remedies for pain as well as 
general, introduced into the vagina. Of course, the anodyne and 
anaesthetic remedial agents constitute our resources for combating 
pain. Opium, belladonna, cicuta, hyoscyamus, and Indian hemp, 
may all be used locally for the pain. The best form for their appli- 
cation locally, is that of a bolus of five grains of pul. opii. I have 
also had the patient to introduce the finely powdered opium through 
a small glass tube, with a small piston of whalebone and cotton. 
It is applied thus to the ulcerated part and walls of the vagina in 
the neighborhood, and very effectually acts as an anodyne. Ten 
grains of the extract of hyoscyamus may be used as a bolus, or two 
grains of ext. belladonna ; and so on with all the anodynes. A grain 
of morphia may be mixed with the ext. hyos. to great advantage. 

Medicated injections often soothe the diseased part very much 
also. The watery extract of opium may be thrown into the vagina 
by a small syringe, and allowed to remain, the patient lying on 
her back for a length of time/ Hydrocyanic acid in solution, 
gtt. xx to a pint of water, passed through the vagina, has a very 
pleasant effect sometimes. Injections of vapors of the anaesthetics 
are highly recommended, particularly by Prof. Simpson. Car- 
bonic acid gas and chloroform are those most used. 

The chloroform vapor may be passed through the vagina by the 
ordinary perpetual syringe, made by the Union Rubber Company. 
The chloroform should be placed in the bottom of a large bottle, 
w T hile the receiving-tube of the syringe may be passed through the 
cork and made air-tight with wax. The other end being inserted 
in the vagina, high enough to almost come in contact with the 
disease, the pumping may be commenced. The vapor will be 
caused to rise in the bottle quite rapidly under the exhausting 
influence of the syringe. Care should be taken not to let the 
tube deep enough in the bottle to come in contact with the chlo- 
roform, lest this fluid, instead of its vapor, pass through the in- 
strument. The vapor thus delivered into the vagina causes a sense 



CANCER OF THE UTERUS. 365 

of heat and glow, which very soon seems to replace the pain. 
When properly done, patients experience great relief from this 
gaseous injection. The same apparatus will do to convey carbonic 
acid gas to the parts. The gas is generated by mixing in the bot- 
tle carb. soda and tart, acid, and then pouring a little water upon 
it. Although I have never yet tried the effect of great cold to 
the part, I have no doubt it would be very effective in relieving 
the pain. It should be applied through the speculum directly 
to the parts diseased, and no other. A small amount of the 
freezing mixture, of two parts pounded ice and one part common 
salt, in a small muslin bag, is the means used by Prof. Simpson. 
It is thought this cold not only relieves the pain, but that it re- 
tards the advance of the disease somewhat. The contact should 
be continued until the parts assume a pale, bloodless appearance, 
when this is practicable, and may be used twice or three times in 
twenty-four hours. With the local remedies for pain, may be 
mentioned the subcutaneous injection of morphia over the sacrum, 
or in the iliac region. 

All these local remedies for pain will, after awhile, fall short of 
the relief demanded by our suffering patients, and we will be under 
the necessity of introducing them into the system in a more effec- 
tive manner. We must resort to their internal use. I need not 
mention the anodynes to which we would resort in such cases ; 
they are well known to the profession. I would, however, caution 
the student not to use opium, when any of the others will answer 
the purpose. Indian hemp will be found to do this more frequently 
than any of the others. They will all fail, eventually, and opium 
will prove the great blessing in such cases. And let me add the 
further caution, to commence with as small doses as will answer 
the purpose, and while we deal liberally enough with the drug to 
get its good effects, increase it slowly as possible ; for with all our 
precautions in this respect, we will be under the necessity of giving 
it enormously. The anaesthetics are too evanescent to be relied 
upon for main remedies, but they will render the influence of 
opium more prompt, and, perhaps, lasting. 

The hemorrhage of cancer will sometimes require prompt inter- 
ference. I think, however, that although the bleeding is always 
ultimately exhausting, that it is seldom immediately dangerous 
from its copiousness. I have generally, when the hemorrhage re- 



6bb CANCER OF THE UTERUS. 

quired interference, depended upon the introduction of small pieces 
of ice frequently repeated. It is often very grateful to the pa- 
tient, as well as haemostatic. Dr. Simpson recommends powdered 
tannin, introduced through the speculum, and placed on the part ; 
but he places more dependence on a paste made of perchloride of 
iron and glycerine. If the bleeding should be very alarming, not- 
withstanding these means, the tampon would be our last resort. 

In fungus and cauliflower excrescences, if the bleeding becomes 
troublesome, they should be broken up with the finger, and an in- 
jection of tinct. ferri chl. made to permeate the mass thoroughly. 
This is generally successful, and attended with very little inconve- 
nience of any kind. The whole sloughs off, and leaves a better 
state of the parts beneath for a time. The fungus is generally 
reproduced, however, and in a short time it is necessary to resort 
to the same expedient. 

The offensive odor emanating from the disease makes it very 
desirable to have some means of correcting it. I should remark, 
with reference to the plans often resorted to, that they are more 
or less injurious to the patient and attendant, viz., the burning of 
sugar, myrrh, &c, in the room. This should be done very spar- 
ingly. For the air, chloride of lime and good ventilation will do 
better than all other expedients. We do not wish to make a 
stronger smell less offensive, to be sure, but we desire to remove" 
the effluvia. Burnt sugar simply fills the room with various other 
less offensive gases which we breathe with them, the original cause 
of the trouble. Chlorine, disengaged from the chloride of lime, 
probably destroys the material floating in the air that offends the 
sense of smell. But the emanation may be lessened by the use of 
chlorinated water used as a wash and injection. The chlorides of 
zinc and soda are used mostly for this purpose, in the proportion 
of one grain to the ounce of water, injected into the vagina co- 
piously. Frequent changes of the linen and bedding of the patient 
are matters of cleanliness that, of course, will readily suggest 
themselves. 

Such is the melancholy paucity of our resources in cancer of the 
uterus. Scarce as they are, however, they may afford the sufferer 
great comfort ; and we should fall short of* our duty if we did not 
industriously employ them to their utmost benefit, as being the 
best the profession can afford. 



CHAPTER XXVII. 

TUMORS OF THE UTERUS. 

Any organized growth within the substance of the uterine walls, 
or depending from or connected with any of its surfaces, may be 
called a tumor. This definition will include polypi of all varieties 
and sizes, from the mere granule that renders the mucous surface 
irregular by its protrusion, to the growth which fills up the uterine 
cavity ; it also includes fibrous tumors of every description, small 
and encysted tumors, &c. These tumors are divided into varieties 
of structure, as the fibrous, fibro-cellular, vesicular, cellular or mu- 
cous, vascular, and encysted. They are also distinguished by 
their position and relationship with the different parts of the uterus. 
Pendulous tumors, of whatever structure or size, are called polypi; 
while the tumors that remain imbedded in the substance, or at- 
tached to the peritoneal surface of the uterus at the fundus, body, 
or cervix, are, in ordinary professional language, denominated tu- 
mors. It is necessary to bear in mind these usages in nomencla- 
ture, in order to rightly understand each other in our conferences 
upon the subject of tumors. 

I shall commence a general view of the nature of these tumors 
by dividing them into varieties according to their structural com- 
position, and then offer some observations on their differences and 
on the effects resulting from them. The fibrous variety is, by far, 
the most common, the most difficult of management, and dangerous, 
of all the benign tumors of the uterus. It is always connected 
with and springs from the fibrous tissue of the uterus. As it grows, 
it either remains imbedded in the wall of the uterus, causing the 
growth of all the tissues in its proximity to an extent sufficient for 
its accommodation, or, if its commencing nucleus is nearer the 
peritoneal surface, as it increases in size, it pushes that membrane 
before it, and extends itself with its serous covering into the ab- 
dominal cavity ; or, again, if its point of origin should be near the 
mucous membrane, that yields and allows the projection of the 



368 TUMORS OF THE UTERUS. 

tumor, as it increases in size, into the uterine or cervical cavity, 
whence it escapes, as it becomes larger, into the vagina. The first 
condition is called intramural, the second extramural, and the last 
polypous tumors of the uterus. In all these conditions the tumor 
may be connected with the fundus, corpus, or cervix uteri. They 
are probably more frequently situated in relation to the neck, 
next in frequency the body is invaded by the tumor, and, least of 
all, the fundus. They occur more commonly in the posterior wall 
of the body and cervix, not nearly so frequently in the side, and 
still less in the anterior wall. This variety of tumor does not 
often remain imbedded in the substance of the cervix, or bulge its 
external surface, but generally projects from the mucous aspects 
of that part of the uterus, and hence is polypous in denomination. 
Fibrous tumors of the uterus are almost always round or oval in 
shape, the intramural most frequently round, the polypous variety 
oftener oval. 

They are organized, at least, so far as to have a complete circu- 
lation of blood; it is doubtful whether nerves ever penetrate them. 
There is quite a difference in the manner of the supply of blood in 
the varieties of fibrous tumors. In the intramural, minute vessels 
enter the substance of the tumors in many places, through the 
loosely connecting tissue ; hence, the arteries and veins are very 
small individually compared to the size of the growth, but on ac- 
count of their numbers afford a sufficient supply. The polypous 
variety and the extramural are supplied somewhat differently. 
The bloodvessels enter the tumor through the stalk, and as the 
support of the whole tumor depends upon a few of them, they are 
comparatively large. This arrangement renders the circulation 
and consequent organization of the polypus more energetic and 
enduring. The attachment is also different. The intramural is 
attached to the surrounding tissues by feeble projections of con- 
nective tissue with their vascular accompaniments, and are semi- 
encysted in their imbedded positions, while the projecting tumors 
are surrounded by their investing membrane, and their connections 
with these membranes more intimate, although of the same nature. 
From these considerations, it results that the vitality of the intra- 
mural is less in force than either of the other varieties. They are 
less capable of sustaining themselves under perturbating influences, 
and more frequently than the other varieties undergo degenera- 



TUMORS OF THE UTERUS. 369 

tion. It is particularly in them that we find copious deposit of 
inorganic substances. Their vitality is so low as to disable them 
from effectively resisting the destructive influence of inflammation, 
in whatever manner it may be set up. Inflammation in them re- 
sults almost always in gangrene or suppuration, or both. We find 
no fibrinous deposits or other attempts at the reparative or protec- 
tive processes of inflammation; they give way, melt down, and are 
discharged under even what, in other substances, would be regarded 
as a moderate degree of inflammation ; hence, the pressure to 
which they are subjected by the uterine contractions during labor 
sometimes awakens certain destruction in their substance. These 
facts are fortunate and instructive. From them has originated the 
great operation of enucleation, as it is called, by which a part of 
the tumor is removed, and inflammation is started up in the mass, 
that speedily terminates in gangrenous solution of it. The poly- 
pus requires more embarrassment of its circulation to cause it to 
slough off, and when artificial destruction is too low down, they 
are almost invariably reproduced. 

These tumors are " made up of fibres resembling those of very 
dense cellular tissue, or of tendinous substances, or of elastic tis- 
sue, presenting various degrees of development, and intermingled 
with cytoblasts, and a granular substance, the abundance of which 
is in inverse proportion to the perfection of the fibrous element 
of the growth." (West.) This dense fibrous structure is some- 
times interrupted by spaces or cavities containing fluid. 

The fibrous bands traverse the tumor in various directions, in 
some specimens so irregularly that they can scarcely be followed ; 
in others they are arranged in concentric rings, &c. They are in 
density and appearance, as they are in structure, very much like 
the hypertrophied fibrous tissue of the uterus. 

Changes of structure are likely to take place ; these changes 
are always degeneracy, in some shape or other, and put an end to 
the vital endowments of the tumor more or less completely. One 
change observed as the effect of want of nutritive energy, perhaps, 
is the conversion of the tumor partially or completely into an 
earthy mass. Calcareous deposits more or less completely occupy 
the whole mass, which remain stationary during the life of the 
patient. These deposits are seldom perfectly continuous with each 
other, but are placed in points and nodules of various sizes ; but 

. 24 



370 TUMORS OF THE UTERUS. 

specimens are said to exist that are so devoid of animal substance 
and so solid as to take a polish by proper friction. 

The tumor after this calcareous degeneration may remain sta- 
tionary, an innocent occupant of its position, or it may be ex- 
pelled wholly from the organ. This is not likely to take place in 
any but the polypous variety. Calcareous degeneration takes place 
most frequently in the extramural variety ; next in frequency the 
intramural is thus affected. The polypous forms seldom undergo 
the chalky change of structure. As I have before remarked, this 
change merely brings the development of the tumor to a stand- 
still ; it is a degeneration from animal to inorganic substance. It 
occasionally happens that in the polypous variety this process of 
degeneration is followed by expulsion ; but the probability is that 
the uterus will become habituated to its presence by the time it is 
thus calcified, and allow it ever afterwards to remain. Nature 
not only brings imperfect relief to the patient by stopping the 
growth of the tumor, but she institutes other processes for a radi- 
cal cure. The extramural variety is cut off, at its point of com- 
munication, from the uterus, and is maintained as a foreign indepen- 
dent substance in the abdominal cavity. So far as I can under- 
stand the facts of this mode of freeing the uterus of the tumor, it 
consists of two processes : the first, an investment, more or less 
complete, with a fibrinous or false membrane thrown out from the 
peritoneal membrane ; and the second, an absorption of the pedic- 
ular connection between the tumor and the uterus. A sufficient 
amount of nutrition is carried on through these fibrinous effu- 
sions to keep up vitality in the tumor. Were it not for this pre- 
vious plastic union with other parts, this tumor would be a source 
of danger by decomposition. The polypous variety is often de- 
tached from the connection with the internal surface of the uterus 
and expelled wholly, or it decomposes and comes away in putri- 
lage and shreds. The detachment is caused by various agencies, 
viz., the powerful expulsive efforts of the uterus, ulcerative in- 
flammation, strangulation in the os or cervix, or rough handling, 
by foreign interference, with the finger, or by efforts in coition, 
&c. The intramural fibrous tumor of the uterus, formidable as it 
is, may be eradicated by the powers of nature. First of all, it 
may cease to grow, begin to decrease in size, and in a few months 
disappear, without any explainable cause, and by an unknown pro- 



TUMORS OF THE UTERUS. 371 

cess, probably on account of such a change of structure as will 
permit its absorption. Secondly, ulceration of the wall of the ute- 
rus, either as the first part of the process or a subsequent item in 
the case, takes place ; the tumor is dissolved down into gangren- 
ous putrilage and evacuated through the vagina. Thirdly, inflam- 
mation — caused perhaps by the pressure of the uterine fibres them- 
selves, in labor or at other times — invades the tumor, and results 
in a mingled process of suppuration and gangrene, ulceration of the 
uterine parietes, and elimination. Speculation will hardly avail us 
in an explanation of all the minutiae of these natural processes of eli- 
mination, and whether we call it eremacausis, enucleation, or by any 
other term, we are not in possession of facts of the right kind to 
elucidate it ; but I am inclined to think that in almost all instances 
the initial process is inflammation, and the destruction of the tumor 
is brought about by suppuration or gangrene, or both conjoined. 

Fibrous tumors of the uterus are of slow growth compared with 
other growths in the pelvic region. Sometimes years will elapse 
before they attain a size capable of mischief, and probably before 
they are detected. Often numerous fibrous tumors exist, and are 
discovered after death, that caused no suspicion of their presence. 
They are seldom solitary : the intramural and extramural varie- 
ties, in particular, generally exist in numbers. A specimen in the 
museum of the Chicago Medical College exhibits dozens of them, 
intramural and extramural. The uterus and its tumors weigh 
about twenty pounds, and they had attained that size in fourteen 
years after the first discovery of them. Some of the tumors in 
this specimen contain a small amount of calcareous deposit, and 
many of them are almost cartilaginous in hardness. 

The uterus scarcely ever retains all its healthy properties and 
proportions with these tumors connected with it. It is almost al- 
ways increased in size or hypertrophied. Sometimes, however, 
there is no perceptible increase noted. Prof. Francis, many years 
ago, reported a post-mortem case of a fibrous tumor weighing one 
hundred pounds, that was developed from a small pedicle con- 
nected with the peritoneal surface of the fundus of a uterus healthy 
in every other respect. The size of the uterus is less influenced 
by extramural tumors than intramural, and the uterine hyper- 
trophy is proportionate to the size of the attachment of the growth. 
A tumor attached by a large pedicle exercises greater influence 



372 TUMORS OF THE UTERUS. 

in this respect, than one with a very small one. In the intramural 
variety, the cavity of the uterus is always increased in length, and 
generally in breadth. The increase will bear a close proportion 
to the size of the tumor. I have known the cavity of the uterus 
to receive the probe to the depth of eight inches in intramural 
fibrous tumors of not very large size. The polypous variety causes 
hypertrophy of the uterus to a less extent than the intramural, but 
greater than the extramural. When situated in the cavity of the 
organ, of course, development sufficient to contain it will necessa- 
rily occur. Should it arise from the cervix inside, less increase 
in proportion to the size of the tumor will take place ; and if it 
arise from the cervix outside the cavity, there will not necessarily 
be any enlargement of the organ. Even where the attachment is 
upon the extremity of the cervix, there is generally some enlarge- 
ment. 

The functions of the uterus, as might be supposed, are nearly 
always disturbed. Although menstruation is sometimes arrested, 
much more frequently it is rendered more than naturally profuse, 
protracted, and frequent. Pregnancy is prevented or influenced 
variously as the location and size of the tumor varies. Extra- 
mural tumors exert comparatively little influence upon this func- 
tion unless they are large, when, by preventing the evolution o£ 
the uterus, they may cause miscarriage. Conception undoubtedly 
takes place less frequently than if they were not at all present. 
Cervical polypi do not very materially embarrass the functions of 
generation. It is to intramural tumors and intrauterine polypi, 
that deviations from correct generative functions are more fre- 
quently attributable. Whether conception can take place when 
the cavity of the body of the uterus is occupied by a polypus, I 
am not informed ; but I should not be surprised if, in rare in- 
stances, this might occur. Conception and perfect gestation are 
accomplished in the presence of very large intramural fibrous tu- 
mors in rare instances. Not long since I examined a patient with 
an intramural tumor of large size, probably as large as a man's 
head ; the uterine cavity lengthened, so as to allow the end of the 
probe to be felt above the umbilicus, through the uterine and ab- 
dominal walls, and cause the appearance of seven months' preg- 
nancy ; and in less than twelve months after the examination, the 
subject of the tumor was delivered of a fine large healthy child, at 



TUMORS OF THE UTERUS. 373 

full term, without accident or difficulty. The pregnancy seemed 
to have arrested the growth of the tumor in this instance. 

Although I have included fibrous polypus in the above general 
description of the fibrous tumors of the uterus, there are a few 
things that it seems necessary to say in reference to it separately. 
The size of the pedicle of the polypus becomes larger, as we leave 
the extremity of the cervix, and proceed up the cavity to the fun- 
dus. Generally, the attachment on the lower end of the cervix is 
quite slender, but the size of attachment at the fundus is generally 
large, in fact, almost as large as any other portion of the tumor. 
Of course, in different specimens, we will find considerable differ- 
ence in this respect. The firmness of these polypi are governed 
also by their locality. They are less firm below, and more above, 
the cavity of the cervix. 

Other tumors of the uterus are softer than the foregoing, and, 
generally, have the mucous membrane for their base of origin and 
support, and hence are not improperly designated mucous polypi. 
An exception to this remark may be found in a rare sort of poly- 
pus, called the fibro-cystic, arising beneath the mucous membrane 
of the cervix. It is formed of fibrous tissue, including small cysts, 
containing a transparent, tenacious fluid, in interspaces, and grows 
to a considerable size. It is always, as far as I know, attached 
in the cervical cavity. The soft or mucous variety of polypus is 
rendered more or less firm, owing to the amount of fibrous sub- 
stance it carries with it. It is often so soft as to become detached 
by slight handling ; sometimes it is firm enough to require con- 
siderable force to destroy or separate it from its attachment. 

The shape and size of these tumors vary very considerably. 
Sometimes they are cylindrical and very long. 

An instance occurred in my practice, where the polypus was 
about the size of the finger, and extended to the vulva from the 
inside of the cervix, where it was attached. It was of equal size 
in its whole length. They are sometimes pear-shaped, and as large 
as an egg, with a small pedicle ; again they are sessile, and not 
larger than a wheat grain. They are often quite numerous in the 
same uterus, but they also occur singly. They may be found on 
any part of the lining membrane of the cavities, but are oftenest 
seated in the cervical cavity, or on the extremity of the neck. I 
think they are more frequently cured by the efforts of nature, than 



374 TUMORS OF THE UTERUS. 

the fibrous variety. They certainly are removed by much slighter 
means than the fibrous. On account of the facility with which 
these tumors are removed, or destroyed, much less importance at- 
taches to them. 

Another form of cervical tumor is sometimes found, which is 
described and illustrated in Dr. Meigs's work on the uterus. It 
is a thin sack, situated in the submucous substance of the cervix, 
which contains an albuminous fluid. It may be felt as an eleva- 
tion, or seen through the speculum, as a bright, translucent tumor, 
the size of a cherry, or even larger. In the only case I ever saw, 
it was on the anterior surface of the cervix, just above the ex- 
tremity of the labium. 

I do not profess to have given a full description of all the tumors 
of the uterus, but I think that the above description is sufficiently 
full and minute to answer all practical purposes. The philosophy 
of their formation, and their effects upon the uterine tissue, are to 
be explained. These tumors are without exception, hypertrophic 
enlargements of some portion of some of the tissues of the uterus. 
A vortex of the fibrous tissue commences growing, and as it 
grows, it assumes something of an individuality that enables it to 
appropriate a larger amount of nutrition than is necessary for the 
maintenance of its usuaLsize ; and hence has begun a tumor that 
will, as a general rule, increase continuously. Unlike the ordi- 
nary tissues of the body, it grows as an individual, independent 
part, and not as a member of the economy, which is bounded in 
its development by the general harmony of the system. A por- 
tion of the mucous membrane likewise may set up an unusually 
energetic and perpetual organization, which enables it to pass be- 
yond the rest of the membrane in growth, and thus protrude and 
hang from it ; or the glands of Naboth may become hypertrophied 
and developed into hygromatous cysts, and remain in situ, or pro- 
trude, carrying with them enough fibrous material to form hydro- 
cystic polypi. 

This assumption of individuality of energy and life in particular 
parts of certain tissues, is always accompanied by other general 
changes in the organ, whether as an effect, concomitant, or cause, 
is yet undetermined. The circulation in the whole uterus is in- 
creased, the quantity of tissue is greater ; in fact, the uterus be- 
comes hypertrophied. Of course, the general hypertrophy is much 



TUMORS OF THE UTERUS. 375 

less than the partial, which gives rise to the tumor. The uterus 
is longer, broader, thicker, and heavier. The vascularity of the 
mucous membrane is greatly increased, particularly in intraute- 
rine tumors. This augumentation of bulk is not always in a direct 
ratio with the size of the tumor, although the fibrous kind of tumor 
generally has more of this effect. 

There is another outgrowth from the uterine neck and inner 
surface which is sometimes classed as polypus, but which is heter- 
ologous in its nature. I allude to the vascular polypus or fungus, 
cauliflower excrescence. The other forms of growth are all, as I 
have before said, hypertrophic developments of existing tissues, 
fibrous, mucous, glandular, &c. This is a true epithelioma or 
fungus, and does not afford in construction any analogy to the 
different uterine tissues. They differ in different specimens as to 
firmness or solidity. Sometimes firm enough to be mistaken by 
the inexperienced for a fibrous growth, at other times they are so 
fragile as to give way with very little handling. There are those 
of intermediate solidity of almost all grades. Although epithe- 
lioma, I do not know that these fungi are necessarily, or even 
generally, connected with cancerous degeneration in the surround- 
ing organs or tissues, and that their malignancy is propagable as 
in other forms of cancer in this locality. Unlike fibrous or other 
benign polypi, they are very difficult of eradication. The destruc- 
tion of the whole tumor and the removal of the whole mass are 
only temporary, in their effect. If the nidus of origin remains, 
the growth will be reproduced. And the tumor attains its former 
size more rapidly after each amputation or removal of any kind. 
They grow quite rapidly as a general thing, and in their progress 
slough off in pieces and grow again. This constant loss and re- 
production of substance is one of the remarkable features of the 
disease. These growths consist very largely of loops of fine arte- 
rial tubes, connected together by a very loose connective tissue, 
and are covered with epithelium merely. 

Early in their growth they may be seen as a slightly elevated 
vascular eminence on some part of one of the lips of the os ; a 
little later, papillary projections show themselves ; still later, the 
whole elevation forms into a^protrusion, which, at last, becomes a 
polypous tumor of various size. Sometimes the vagina is so dis- 
tended by the tumor as to completely fill the lower half of the 



376 TUMORS OF THE UTERUS. 

pelvic cavity, and the growth protrudes in bleeding shreds from 
the vaginal orifice. 

Symptoms. — Two kinds of symptoms first arrest the attention 
of the patient and medical attendant, viz., discharges and pres- 
sure. The former kind originates, for the most part, in the un- 
natural vascularity of the uterus, and the other in the embarrass- 
ment to pelvic organs, caused by the pressure of the morbid growth 
upon them. These symptoms are not merely the indices to dis- 
ease, but the effect of it upon the general health, and they require 
interference for their amelioration or cure. Thus the hemorrhage 
exhausts the patient, and the pressure upon the bladder or rectum 
does great mischief in various ways ; and after the tumor rises out 
of the pelvis, pressure may be the cause of much damage to the 
abdominal organs. Hemorrhage is a symptom which is common 
to all uterine tumors. It is much more common in the polypous 
variety, rather less so in the intramural form, and not very fre- 
quent in the extramural fibrous tumors. Hemorrhage is so con- 
stant a symptom in polypus of the uterus that we expect it; and 
it is the almost invariable cause of our advice being sought for. 
It is remarkable, too, that the size of the polypous growth makes 
but little difference in this respect. A very minute tumor in the 
cavity of the cervix or corpus uteri may exsanguine our patient, 
and the larger produce quite a moderate amount of discharge. 
The hemorrhage indicating uterine growths is apt to show itself 
first by increase in the quantity of discharge at the menstrual 
period, then by the frequency or rather protracted duration of the 
discharge, so that the interval becomes shorter ; or there may be 
constant hemorrhage, the menstrual epoch being designated only 
by the profusion compared to other times in the month. Some- 
times the hemorrhage of menstruation is not greater than ordinary, 
but there is bleeding at intervals between the monthly periods, 
slight or profuse, owing to other circumstances. 

Again, we meet with instances when, without premonition, hem- 
orrhage bursts forth in large and exhausting quantities, to be 
followed by cessation of long duration, reappearance, &c. The 
period of the growth or advance of the tumor at which hemor- 
rhage may begin varies greatly. The growth may develop to a 
pretty large size before any sign of its existence appears, so that 
when the symptoms lead us to suspect a tumor, we are surprised 



TUMORS OF THE UTERUS. 377 

to find it so large. Finally, tumors attain to great size, both in 
the walls of the uterus and depending from the cavities and cervix 
of the organ, without causing any hemorrhage. These cases, how- 
ever, are not common. We should always suspect the presence of 
a growth where there is protracted or frequently recurring hemor- 
rhage ; and if there is none in the vagina, we ought to remember 
the frequency with which intrauterine polypi or intramural growths 
cause it, and examine for them. 

Although polypous growths sometimes cause tenesmus, they do 
not often cause serious pelvic distress. The large intramural 
growths often give rise to symptoms from'pressure as the first evi- 
dence of their presence. Difficulty of urinating or defecating 
causes the patient to suspect something wrong. If the tumor is 
in the anterior wall, the bladder is first affected ; if in the poste- 
rior wall, the rectum suffers, &c. ; and finally, if the tumor con- 
tinues to grow, both these canals may be pressed so firmly against 
the bones of the pelvis as to arrest excretion through them. A 
distressing instance of this kind recently came to my notice, in 
which the patient was being rapidly prostrated by the anxiety, 
pain, &c, of protracted efforts, aided by medicine and instruments 
to evacuate the bladder and rectum, both of which were almost 
completely occluded by pressure. Upon examination, the pelvis 
was found impacted by one of the offshoots from a large fibrous 
tumor that reached nearly to the umbilicus. By judicious efforts 
the tumor was lifted above the inferior strait, and kept so for some 
days, when there was no further tendency to return to its original 
situation, and the relief experienced immediately after it was lifted 
up became permanent. Pelvic distress from pressure, however, 
does not always take place ; some of these tumors rise out of the 
pelvis without causing any inconvenience. When this is the case, 
and there is no pressure, a long time ordinarily elapses before the 
tumor gives the patient much inconvenience. Sometimes the 
amount of pressure is so slight upon any particular organ that the 
tumor is not announced by any symptom until the increase in the 
size of the abdomen gives rise to suspicion. Not unfrequently be- 
fore the tumor rises out of the pelvis, or soon afterwards, it exerts 
great pressure upon the nerves passing through that cavity, caus- 
ing pain, paralysis, or cramp in the parts to which the nerves are 
distributed ; or pressing upon the veins induces oedema, and, in 



378 TUMORS OF THE UTERUS. 

some instances, a state of things closely resembling phlegmasia 
dolens. An instance of this latter kind of trouble is now in charge 
of a friend of mine in this city. The limb is so large and un- 
wieldy that the patient is scarcely able to walk. As the tumor 
attains to a still higher position, the abdominal organs suffer from 
pressure, and the patient's distress is increased by indigestion, 
vomiting, jaundice, pains in different parts of the abdomen, great 
distension, and pain from the great muscular tension. 

After a greater or less time, the continued and prolonged em- 
barrassment to those vital organs which are centred in the abdo- 
men, produces marasmus, which is succeeded by death. Some- 
times the tumor does not rise out of the pelvis, but a part of it 
grows up from that contained in this cavity, and to a greater or 
less extent fills up the abdomen. In such cases, we may have all 
the symptoms of great pressure in both the pelvis and the ab- 
domen. 

Diagnosis. — We are seldom called upon to render a diagnosis 
in a case of uterine tumor, until some one of the distressing symp- 
toms enumerated above have harassed the patient very consider- 
ably. The symptoms of hemorrhage and pressure are very likely 
to be the first. Of all the symptoms above mentioned, hemor- 
rhage is the only one that points to uterine growths ; pressure 
may be caused by any other sort of tumor as well as tumor of 
the uterus. I do not think that position is at all distinctive, as 
movable tumors are likely to assume a central position. Fibrous 
tumors are harder than almost all other tumors in the pelvis or 
abdomen that are movable. They are of greater consistence than 
ovarian growths or hydatids of the abdominal organs. The only 
enlargements or growths likely to equal in denseness the fibrous 
uterine tumor are scirrhus and hypertrophy of the liver and 
spleen, or concretions in the intestinal canal or other hollow vis- 
cera. Their contour is generally globular, and when not so they 
may be discovered to consist of globular bodies, joined together and 
separated by well-defined fissures, penetrating not very deeply 
into the substance, their edges being rounded instead of sharp. 
The great item of diagnosis in these cases is the determination of 
the attachment to the uterus or not. By careful and diligent 
manipulation and the use of the probe, we can almost invariably 
determine whether the tumor is connected by continuous tissue 



TUMORS OF THE UTERUS. 379 

with the uterus. If it is connected with the uterus, it is of course 
a uterine tumor ; if not, its attachment elsewhere removes it from 
the category of these tumors which are under consideration at 
present. In making this statement, it is hardly worth consider- 
ing the possibility of preternatural adhesion between tumors 
springing from other organs. If there is the close attachment 
we always find between this organ and its outgrowths, there will be 
consentaneous motion of the uterus and tumor in every direction. 
In moving the tumor in any direction the uterus will follow or be 
moved by it ; if the uterus is moved in any direction the tumor is 
impressed similarly. If the growth is not attached to the uterus, 
and consequently is not uterine, this organ may be moved in al- 
most every direction without imparting motion to the tumor, and 
vice versa. In using this test we should not be satisfied by mov- 
ing either in any one direction, but should move them in every 
practical manner, — up, down, back and forward, sidewise and 
diagonally. The particular means and modes of doing this must 
now be reviewed. We should first, if possible, by digital examina- 
tion find the uterus and ascertain its relative position to the tumor ; 
if the tumor reaches above the symphysis, we should next lay hold 
of it with the other hand, and move it from side to side, from be- 
fore backward, and, when practicable, lift it up, in the meanwhile 
closely watching, with the introduced fingers, the eifect of these 
movements upon the uterus. If the tumor is not attached, and 
consequently not uterine, we may easily feel the motion of the 
tumor through the uterus, while we can be perfectly satisfied 
generally that the uterus itself, although moved to some extent, 
is not dragged with the tumor when its position is changed. In 
some instances, I have had good reason to be well satisfied with 
an effort at rotation of the tumor ; when not too small, an assistant, 
properly instructed, will often succeed in partially twisting the 
tumor upon its vertical or horizontal axis. When this motion is 
imparted to the tumor it will be quite sure to give a correct sen- 
sation to the finger in contact with the uterus. If the uterus is 
in a position to be controlled by the finger, we may move it up- 
ward and downward, from side to side, backward and forward, and 
rotate it, while we keep close watch, by the senses of touch and 
sight, of the movements of the tumor. It is not unusually the 
case that we can satisfactorily ascertain the whereabouts and rel- 



380 TUMORS OF THE UTERUS. 

ative position of the os uteri, while we cannot define the position 
of the body of this organ. In these cases the uterine sound or 
probe will aid us very materially. There are several things to be 
remembered by the inexperienced in the use of this instrument, 
to insure satisfactory results. The sound should be soft enough 
to bend to any required shape, and yet firm enough to retain that 
shape under the application of moderate force. I think the sounds 
for sale at the instrument makers are generally too hard ; they 
should be small too, — the bulbous extremity not more than the 
eighth of an inch in diameter ; even slightly under this size will 
often do better. 

When we have ascertained the position of the os uteri, the probe 
should be introduced into it as far as it will go without force, va- 
rying its direction every way. This trial, if it does not succeed 
in sounding the uterine cavity, will give us some idea of the direc- 
tion of it. If we do not succeed, we should bend the instrument 
slightly, and give it another trial similar to the first; and still if 
we do not succeed, we should flex it still more and try again. By 
patience, perseverance, and gentleness, we will, after awhile, pass 
it to the fundus. 

In most cases of fibrous tumor, the probe will pass farther into 
the uterus than in a natural state of that organ, the cavity being 
elongated. The probe will pass three, four, six, and sometimes 
eight inches. On more than one occasion, I have felt the end of 
the probe above the umbilicus, through the abdominal and uterine 
walls. When once introduced to the end of the cavity of the 
uterus, we may move the organ in every direction, which will 
affect the tumor if attachment exists. When the probe is thus 
introduced, we should place our finger on the tumor per rectum, 
if it is small, or over the symphysis pubis, if large enough, 
while the uterus is made to move in every direction, and rotate, 
or nearly so. I think, in some cases, the finger in the rectum will 
appreciate movement imparted to the tumor with more certainty 
than when placed on the abdominal walls, or even in the vagina. 
There is very little doubt left by an investigation conducted in the 
manner above directed, with the finger and probe, &c. 

Pregnancy should be excluded from the questions occurring in 
order to clear up a diagnosis, before the probe is made use of, 
lest the membranes be ruptured, and abortion occur. This may 



TUMORS OF THE UTERUS. 381 

generally be done by remembering the signs of that condition, and 
making thorough examinations with the hand, fingers, &c. 

Although the difficulties of diagnosis are very much greater in 
some instances of large intramural fibrous tumors, yet we occa- 
sionally meet with perplexities in deciding whether a vaginal 
tumor is polypous. Perhaps the only condition that is likely to 
be mistaken for a polypus, is chronic inversion of the uterus ; 
and, as the history is not always to be relied upon, we are under 
the necessity often of manipulating for that purpose. The probe 
and finger will readily make the distinction. If the uterus is in- 
verted, the probe will pass up the same distance all around the 
tumor, — before it, behind, and at the sides ; if it is polypus, it 
will not pass above the reach of the finger on but one side, and in 
that direction will sink to the depth of the uterine cavity. The 
finger, in the case of inversion, is obstructed alike on all sides ; 
while in the case of the polypus, it will mount higher upon the 
tumor in one direction, which ordinarily is in front. Probably the 
most difficult of detection are small intrauterine polypi. 

The symptoms which always induce us to suspect the presence 
of these bodies is persistent, exhausting, and unaccountable hem- 
orrhage. There are no symptoms by which we can arrive at cer- 
tainty in this respect ; but when hemorrhage persists, in spite of 
judicious remedies diligently and rationally applied, we should not 
fail to examine the cavity of the uterus in every possible way. 

The shape and size of the uterus should be investigated by the 
finger and probe as completely as possible, and if they yield no 
satisfactory results, we must open the os and cervix, so that we 
may see the contents of all the inside of the organ. This may be 
done by a sponge properly prepared. This plan was perfected by 
Prof. Simpson, of Edinburgh, to whom the profession is indebted 
for many ingenious and useful suggestions in physical examina- 
tions. The sponge should be fine, and saturated with a solution 
of gum-arabic ; after which it must be wrapped with twine in such 
a way as to compress it to its smallest possible dimension. With 
a little care, we may make the piece take a conical shape, more 
particularly if we trim it with that view. In this way the sponge 
can be compressed so as to occupy a space of probably one-sixth 
the size when expanded by moisture. After applying the twine, 
we should let it lie for several davs, until it is dried and solid. If 



382 TUMORS OF THE UTERUS. 

not of the right shape, the sponge thus prepared should be cut 
into a long cone with a sharp knife. It is a good plan, and will 
facilitate the wrapping to insert a probe or stiletto into the large 
end of the sponge, and let it there remain until dried. When we 
wish to dilate the os and cervix uteri, we insert a small cone of 
this sponge, and push it up as far as w T e can, and then allow it to 
remain until the moisture of the parts expands the sponge ; the 
cavities will gradually dilate under this expansive influence. It 
takes about twenty-four hours for the sponge to expand the parts 
as much as it is capable, if it is tightly embraced by them ; at the 
end of this time, it will be so loose that it may be easily removed 
with forceps. To render the removal easier, it is usual to attach 
a thread or twine to it before inserting. Upon the removal of 
one piece, it should be replaced by another considerably larger, 
pushed up as far as it can be made to go with reasonable force. 
It will require but a few days, perhaps only two, sometimes more, 
to bring the cavities in a condition for thorough inspection, when, 
if there are any growths, they will be apparent, and subject to 
such treatment as may be necessary. In the use of these means 
for dilating the os and cervix, we will be very much aided by the 
speculum. 

Although encysted tumors of the cervix may sometimes be dis- 
covered by the finger, the diagnosis will hardly be complete until 
we inspect the part thoroughly through the speculum, when they 
will present themselves in an unmistakable manner. Small polypi 
in the mouth, and even protruding slightly from it, may not always 
be discovered by the finger. We should, in all obscure cases of 
hemorrhage, make use of the speculum, if our diagnosis should 
not be clear without it. The tyro need not fear these modes and 
means, as the parts are not damaged by them if conducted with 
reasonable care. 

Prognosis. — The prognosis of uterine tumors, considered in a 
general way, may be regarded as unfavorable. Once started into 
active growth their tendency is to grow constantly, so long as the 
energies of the patient last, and with their growth the production 
of destructive symptoms, more or less rapidly, varying with at- 
tendant circumstances and complications in different cases. Al- 
though this may be said to be the condition of things generally, 
there are some happy exceptions to the rule. Some tumors, after 



TUMORS OF THE UTERUS. 383 

growing for a time, cease to increase in size, and remain stationary 
for the remainder of the patient's life, or they grow so slowly as 
not to incommode the sufferer to a dangerous degree until the end 
of life is accomplished by age, or terminated by some other cause. 
Again, nature accomplishes a cure by inflammation, evacuation, 
expulsion, or absorption. These exceptions to the rule of a con- 
stant tendency to death are, it is true, not very numerous, but 
sufficiently so to be taken into consideration in making up our 
judgment. In particular instances there are often circumstances 
that will enable us to determine the rapidity with which the fatal 
issue is approaching, or the competency of nature to avoid it en- 
tirely. On one occasion, at least, I met with a case that seemed 
to be rapidly undermining the powers of the patient by exhausting 
hemorrhage, and the end appeared to be near at hand, when, with- 
out any apparent reason, it suddenly ceased to give any further 
inconvenience from the hemorrhage, although it still grew with 
tolerable rapidity. 

The modes "by which these tumors produce death are through 
hemorrhage and great pressure. The patient dies of hemorrhage 
suddenly, on account of a severe and continuous drainage for days, 
or hemorrhage proves fatal in a chronic way. An eruption of 
hemorrhage, so severe as to cause death the first time, is very 
rare, though such cases do occasionally occur. Repeated recur- 
rent attacks, at intervals of weeks or even months, induce organic 
diseases by vitiating the blood primarily, or so impoverish the 
blood as to render it incapable of supporting the vital functions, 
and fatal prostration occurs. We judge of the probable fatality 
of each case from the copiousness and frequency of the attacks, 
and by the robustness or delicacy of the constitution of the patient. 
After all, however, we should be very cautious in our prognostic 
calculations as to the effect of this symptom, since sudden changes 
are liable to take place at any time. Death comes sometimes as a 
consequence of the pressure on some organ or organs. When this 
is the case, its approach is very gradual, and the various steps in 
that direction are often obscured, so that we may not perceive 
them. The bladder may be pressed upon, irritated, and eventually 
mucous inflammation takes .place, and spreads up through the 
ureters to the kidneys, and disorganization in these important ex- 
cretory organs be the more immediate cause of death. Or again, 



384 TUMORS OF THE UTERUS. 

the indigestion, vitiation of nutrition, and their consequences, 
caused by pressure upon the rectum, may bring about fatal disaster 
to the organs of the abdomen. Pressure upon the veins may cause 
fatal stoppage of their circulation, or induce phlebitis and its 
direful accompaniments. In some of these, and, in fact, many 
others, pressure may lead to fatal addenda and complications. 

But complications independent of the tumor may act very un- 
favorably on the course of the tumor, or be rendered dangerous 
by the presence of the growth. Pregnancy is one of these, and al- 
though a natural function, its influence on the uterus is so great — the 
organ in which the tumor grows — that the case often may be much 
aggravated by its supervention. Pregnancy, by increasing the 
afflux of blood to the uterus, and its general hypertrophizing effects 
upon that organ, causes the tumor to grow sometimes very rapidly. 
It is true that in certain places, where great pressure is exerted 
upon it by the developing ovum, the pressure may counteract these 
effects. Where this is the case, at the end of pregnancy the patient 
is much worse off than at its beginning. But, perhaps the worst 
effects of the coexistence of pregnancy and a fibrous uterine tumor 
result from a violent termination to the progress of gestation in 
abortion, and the inflammation that ensues. The determination of 
blood to the uterus on account of the presence of the tumor, the in- 
creased size and number of arteries and veins, greatly add to the 
intensity, extent, and consequences of the inflammation so gene- 
rally attendant upon miscarriages. There can be no doubt, too, I 
think, that the peritoneum is more susceptible of destructive in- 
flammation when the uterine envelope derived from it is rendered 
more vascular, or at least hypertrophied, by the enlargement of the 
uterus. In view of these considerations, we should regard the su- 
pervention of pregnancy with anxiety. It should be remembered, 
however, that the inflammation invading the tumor may have a 
salutary effect upon it by arresting its growth, or by causing it to 
be eliminated by suppurative inflammation. Should pregnancy 
not be interrupted by the growth, and proceed to full term, the 
apprehensions usually indulged are increased to a manifold degree, 
as there is much more danger of inflammation post partum. The 
tumor must be very violently compressed by the throes of labor, 
and likely to be attacked by inflammation, which may spread to 
other parts, and cause great mischief and suffering, if not death. 



TUMORS OF THE UTERUS. 385 

Hemorrhage is more likely to occur and more dangerous than in 
ordinary cases of labor. Gangrene or suppuration in a large tumor 
may lead to death on account of the shock, exhaustion, or phle- 
bitic inflammation which may be produced. Unfortunately, the 
prognosis is not rendered much better, so far as the ultimate ter- 
mination of the case is concerned. Relief may be afforded from 
some of the distressing symptoms by proper palliative treatment 
in intramural tumors, but very few of the cases are susceptible of 
radical or surgical treatment. The polypous variety, while they 
may do nearly or quite as much damage as the intramural in one 
way, viz., by the hemorrhage they cause, are nearly always curable 
by surgical means. 

Epitheliomatous growths from the cervix are much more dan- 
gerous than the fibrous or other benign polypi. They almost in- 
variably prove fatal without treatment, wearing the system out 
by the exhausting discharges from them ; and, by vitiating the 
blood, they bring about diseases arising from poison in that fluid. 
Treatment is much less certain than in the other growths, and a 
radical cure by surgical means is the exception to the general rule. 
There are unquestionable cases of cure after amputation of the 
cervix, but many more cases of failure could be recorded. 

The hygroma and other encysted growths of the neck of the 
uterus are quite amenable to treatment. If left to pursue their 
own course, they cause a great deal of suffering ; and, in persons 
of feeble constitution, exhaust by the draining hemorrhage they 
cause, until the patient falls an easy prey to some intercurrent dis- 
ease, or they may cause death directly by the anaemic condition of 
the system they produce. 

Treatment of tumors of the uterus should be palliative and radi- 
cal ; the palliative combats the symptoms arising from the presence 
of the tumor, ameliorates the condition of the patient, and often 
enables her to live longer than she could without it. It is some- 
times the only treatment practicable. The radical treatment has 
for its object the cure of the patient, by removing the tumor, or 
the arrest of its growth. It is quite impossible to foresee and pro- 
vide for the treatment of every inconvenient or dangerous symp- 
tom that may arise during the existence of these tumors, and I do 
not intend to make the attempt ; but there are symptoms of a very 
grave character, which occur so frequently under such circum- 

25 



386 TUMORS OF THE UTERUS. 

stances, that we should anticipate them, and be prepared for their 
occurrence. Hemorrhage, for instance, as a general thing, is 
present in cases of uterine tumors ; and that its efficient treatment 
is a matter of the greatest importance, the student will under- 
stand. Fortunately, its control, as it takes place from the ute- 
rine cavity, is as certain almost as the employment of the means. 
These are, for the most part, mechanical, and should be resorted 
to with boldness and energy where the urgency of the case demands 
them. I shall leave their description until after I have mentioned 
the medicinal treatment of hemorrhage. 

Hemorrhage does not always proceed to a dangerous degree, 
although it may be sufficiently copious to make it a symptom of 
great distress and inconvenience. The medicines for hemorrhage 
are the whole class of astringents. Some of them have gained 
quite a distinction for efficiency, while others are not used at all. 
When hemorrhage comes on in a threatening manner, the patient 
should be confined to the recumbent posture, in a cool room, al- 
lowed nothing for ingesta but cold acidulated drinks, and kept as 
free as possible from all causes of excitement. Cold should be ap- 
plied over the symphysis pubis in such a way as to keep up a steady 
low temperature. Ice in a beef's bladder, laid over the part, or 
small pieces of it may be placed between two thin cloths, and al- 
lowed slowly to melt, and run over the person of the patient. 
The hips should be elevated by an air or water cushion, while the 
head and shoulders should be kept low as is compatible with the 
comfort of the patient. In moderate cases, it will be sufficient to 
give, in addition to the above treatment, twenty drops of the aro- 
matic sul. jacid, in sufficient water to largely dilute it, every four 
hours. Sugar of lead in two-grain doses, combined with one grain 
of opium in pill, every four hours, is regarded as an efficient as- 
tringent by most physicians, in such cases. Gallic acid, in doses 
of eight to ten grains, administered as often, will sometimes an- 
swer an excellent purpose. Oil of turpentine, in grave cases, may 
be given in drachm doses, in an emulsion, every hour, with most 
excellent effect. But astringents may be administered by injec- 
tion with very good effect. The tr. ferri chl., for instance, in- 
jected into the cavity of the uterus, so as to come in contact with 
the bleeding surface, will seldom fail to answer the purpose of 
greatly lessening, if not entirely stopping, the hemorrhage. A 



TUMORS OF THE UTERUS. 387 

good way of operating is to introduce a small male elastic catheter 
into the cavity, and, if possible, to the fundus, and through this, 
with a hydrocele syringe of hard rubber, throw a drachm of the 
tincture. The injection should be made with very little force. A 
strong solution of nitrate silver, tannin, or other astringent, may 
be used in place of the tincture. 

An expedient of great efficiency is the introduction of the pow- 
der of tannin, or gallic acid. This can be done through a cathe- 
ter, with a stylet covered with a piece of lint. These modes of 
using astringents are far more efficacious than taking them into 
the stomach. 

The mechanical treatment consists in the various sorts of tam- 
pon. In a great many instances, to stop the vagina entirely by a 
plug or tampon will be all that is necessary to check the hem or-,, 
rhage. And this should be resorted to without delay, as it is 
not difficult to do, is attended with no danger, and very little in- 
convenience. 

In the present advanced condition of the mechanics of medicine 
and surgery, I need not say that the handkerchief, the old clothes, 
cotton batting, and sponge, should be, and I think generally are, 
discarded. The gum elastic air-bag, is the only tampon justified 
by anything but extraordinary circumstances ; and when not within 
reach at the time of our great necessity, should be procured at 
once, and the other plugging expedients be replaced by it as soon 
as it can be procured. The application of the air-bag is so simple, 
that it may be left with the patient to be used until the physician 
can be called. 

The patient, or the nurse, should be directed to introduce it— 
upon the supervention of the hemorrhage — in a collapsed state, 
and then, by means of the inflator, to blow it up until the disten- 
sion produces slight pain. This will prevent the blood from flow- 
ing out of the vagina, and fill the upper part of the vagina and 
uterine cavity with coagula, and thus stop the hemorrhage. This 
distension should be increased in an hour or two, if the hemorrhage 
occurs ; if not, this will not be necessary. By managing the col- 
peurynter, or elastic air-bag, in this way, the -blood may be saved, 
as a general thing, with very little loss. But in cases where the 
danger is imminent, the os uteri may be plugged, and the flow 
stopped with still less loss of blood, and, as I have thought, with 



388 TUMORS OF THE UTERUS. 

* 

more ease and certainty. There are two instruments used for this 
purpose ; one is a small cylinder of gum-elastic tube, with a small 
bulb on the end of it, large enough to fill the cavity of the cervix. 
This may be introduced, by means of a probe, entirely within the 
os, and then inflated. The other is a cone of compressed sponge, 
iust large enough to pass into the cavity of the cervix. When 
well introduced, the compressed sponge will certainly check the 
hemorrhage. It very soon fills the cavity of the neck so closely, 
that the blood will not pass it ; coagulation inside of the uterus 
takes place, and the bleeding is stopped. 

All these resources against hemorrhage are mentioned more par- 
ticularly with reference to the intramural variety of tumors, as, 
indeed, it is seldom that they are needed in any other variety. 
Polypous tumors, in any of their forms, seldom induce the sudden, 
copious, and almost uncontrollable bleeding that occur in connec- 
tion with the above-mentioned form. The injection, the tampon, 
and the compressed sponge, may, however, be used even in some 
cases of these to great advantage. 

It is a nice point, as well as a very important one, to know when 
we ought to depend upon palliative remedies for hemorrhage, and 
when we should abandon them for the radical surgical treatment. 
Our object being to save the life of the patient, we cannot afford 
to see it sacrificed by the loss of a fatal amount of blood ; nor can 
we resort to the dangerous expedient of removing the tumor, until 
satisfied that it is our only resort against otherwise inevitable 
disaster. 

Unfortunately, no absolute rule can be found by which we may 
be governed in all cases, but we have some considerations that 
ought to influence us. If the hemorrhage is so serious a symp- 
tom as to threaten the existence of the patient with immediate 
danger, if the tumor is in the most favorable condition for an 
operation that intramural .tumors present, if the constitution of 
the patient is not embarrassed by any other severe or depressing 
disease, and if our temporary treatment fails or is impracticable, — 
and this last objection will sometimes show itself, — we should en- 
deavor to get rid of the growth by surgical means. But while the 
hemorrhage is moderate and controllable, or controllable when 
sudden and severe in its eruptions, the patient not much depressed 



TUMORS OF THE UTERUS. 389 

by it, and cheerful to bear her burden, we may be satisfied with a 
skilfully applied palliative treatment. 

But another state of things renders curative treatment inadmis- 
sible, and makes the palliative the only practicable means ; I 
mean when the tumor has grown so large as to preclude the pos- 
sibility of its removal. It often happens that the pressure of a 
tumor on the pelvic organs causes a great deal of suffering. In 
these cases it is generally because the tumor is large enough to 
almost or wholly fill up the cavity. When this is the state of 
things we may often lift it up to and above the superior strait, and 
thus lighten the pressure, affording relief. It may be necessary 
to make use of artificial support in the vagina sometimes, but at 
others, by enjoining the recumbent posture for a few days, watch- 
ing and keeping the growth lifted up, it will not again settle back. 
I have seen more than one instance where this kind of palliation 
made the patient comfortable for several years. "When the tumor 
is not so large as to fill up the whole pelvic cavity, it may be so 
situated as to press upon the bladder or rectum, sciatic nerves or 
urethra. We may often relieve these cases by changing the posi- 
tion of the tumor with the hand, or with some instrument, for 
the purpose of keeping it placed artificially, causing the patient to 
assume and remain in such a position as may be necessary to ful- 
fil these indications. This idea in the treatment of these tumors 
will serve a good purpose after the tumor gets so large as in a 
great measure to fill up the abdomen. The recumbent posture, 
on the side, will relieve the pressure on the vessels near the spine 
and the kidneys. And when the tumor is irregular in shape, so 
as to press upon the viscera upon one or the other side, a position 
may be assumed that will take the pressure off of the part suf- 
fering. 

In addition to these considerations there are others which have 
reference to the general health of the patient. The secretions, 
excretions and nutrition should be corrected and promoted by 
the remedies suggested by the particular case. The patient 
should be kept as comfortable or as free from suffering as possi- 
ble, and in as vigorous a state of health as practicable. 

The radical or curative treatment of tumors of the uterus have 
for their object sometimes the complete removal of them. In the 
nature of things this is for the most part necessarily surgical. 



390 TUMORS OF THE UTERUS. 

These organized growths are engrafted upon the system, and are 
supported by the same processes of nutrition that other parts of 
the body are sustained by ; so that no special medicinal treatment 
exercises much influence over them. They cannot be singled 
out as the objects at which medicines can be directed through the 
stomach, and thus poisoned or etched away by the absorbents, 
and removed. It should be stated, however,- that the profession 
are not all agreed upon this point, and cases occasionally occur 
that would give color to the idea that sorbefacient influences can 
be exerted upon them. A certain number of remedies are cred- 
ited with curative effects upon almost all sorts of tumors, and 
among them uterine tumors. Iodine, I think, stands at the head 
of the list; either combined with or administered alternately with 
mercury, or alone. Less confidence is awarded to it now, how- 
ever, than formerly. Mercury probably stands next in the 
esteem of the profession. These remedies to have any good effect 
must of necessity be continued a long time. I need not speak of 
the caution with which mercury particularly should be adminis- 
tered. When injudiciously used it is an agent capable of great 
mischief. Its full sorbefacient effects may be obtained by very 
small doses : say the eighth of a grain of calomel twice a day until 
it begins to produce a perceptible effect upon the bowels or gums, 
and then wholly intermitted for as long a time as it had been ad- 
ministered; when it may be again resumed for the same effect. 
Continued for several months in this way it must have all the 
effect of which it is capable. During the administration of the 
mercurial thus, care must be taken to watch its effects upon nu- 
trition^ and if the patient becomes prostrated, tonics, nutritious 
diet, and even stimulants, should supplant It, at least for a time, if 
not permanently. Iodine does not often affect the patient very 
injuriously, so that we may give it in much larger doses and con- 
tinue it longer with less apprehension. Yet occasionally it is not 
tolerated, and produces very disagreeable effects. The alkalies 
have had a solvent reputation with reference to these tumors. 
Liquor potassa is a favorite article, and many other preparations 
of potassa are also used, as is soda in various forms. During 
the course, whatever be the sorbefacient article used, great care 
should be taken to keep the general health to its standard at 
least. When it is remembered that these tumors disappear, so far 



TUMORS OF THE UTERUS. 391 

as we can judge, spontaneously, and that they are interrupted in 
their growth by trifling and sometimes inappreciable mechanical 
causes, there will, I think, be room to doubt whether the above- 
mentioned medicines have any effect upon them. For my part, in 
a limited experience, I have not learned anything favorable to 
them in this respect, and place no reliance upon them whatever. 
Some of these medicines aid us in subduing the inflammatory 
complications which sometimes spring up and render the danger 
greater. 

We" are very much more successful in the radical treatment of 
these tumors by surgical means. Some of them are safely and 
certainly cured by surgery ; others are sometimes amenable to the 
same agency, but their cure is attended with great danger ; while 
there remain a large number that are wholly beyond the reach of 
the surgeon. I am not aware that any living surgeon advises the 
removal by surgery of an extra-uterine fibrous tumor, even when 
we can decide that the pedicle or point of attachment is small ; al- 
though this operation has been performed. The operation would 
consist in cutting down through the abdominal walls until the 
tumor is exposed, and then, after tying the pedicle with a double 
ligature, cut it off, and then close -the wound. The intramural 
variety is becoming, under certain conditions and circumstances, 
the subject of the surgeon's knife. What are the conditions which 
demand and justify an attempt at removal V 

Since writing the above, Prof. H. R. Storer, of Boston, in the 
American Journal, for January, 1866, publishes an account of the 
removal of a large fibrous tumor with a part of the uterus by ab- 
dominal section, and by a very ingenious and learned argument, 
tries to convince the profession that this operation should be ad- 
mitted as legitimate. I confess, however, that I am not convinced, 
nor can either follow his example or advise others to do so. Dr. 
Koebeale, of Strasburg, teaches the advocates the legitimacy of 
the operation. 

Dr. J. Wood, Surgeon to the Commercial Hospital, Cincin- 
nati, records in the January (1867) No. of the Lancet and Ob- 
server, a case in which he describes an operation by himself for 
the removal of a fibrous tumor. The tumor and uterus were both 
removed, and the patient recovered. 

The surgeon should well consider all the circumstances of his 



392 TUMORS OF THE UTERUS. 

patient before he decides what to' do. The general conclusions to 
which he must be driven before he should decide to submit the 
fate of the woman to so dangerous a procedure, are, first, that the 
removal of the tumor is certainly practicable ; and second, that 
without its removal the patient is in imminent danger of death, 
and that she can assuredly live but a short time if the tumor is 
allowed to remain. To come to the first conclusion, the growth 
should be low and within reach of the finger and instruments, with 
which to completely examine it. If it is in the fundus or upper 
part of the walls, and does not occupy the pelvis at all, the cer- 
tainty of being able to remove it by the operations I shall describe 
cannot be entertained. We must be able by a proper examination 
precisely to define its relationship with the cavity of the uterus 
and with other viscera, as the bladder and rectum. Without this 
can be done, the danger will be great when it is not very large. 
The latter proposition cannot be true unless it is a hemorrhagic 
case, or the tumor has begun to cause destructive pressure upon 
some of the pelvic organs. 

It is well known that there are cases in which hemorrhage proves 
fatal before the tumor attains a very great size, and that in other 
cases there never occurs any serious amount of hemorrhage. If 
an operation is determined upon as necessary, the tumor should 
be studied with reference to it. This may be done with the probe 
and finger. If the tumor is in the anterior wall, the probe ought 
to be introduced into the bladder, and the finger in the vagina ; or 
while one probe is in the cavity of the uterus, another may be in- 
troduced into the bladder, and the finger into the rectum. Some- 
times the tumor, when near the cervix, is developed downward, so 
as to deploy into the vagina at the top and intrude into it, push- 
ing the wall of the uterus before it. When this is the case, it may 
be attacked at the most dependent part. In many other cases, 
the cervix is not at all developed, and the vagina is attached to it 
without being opened out. We cannot operate in such cases with- 
out dilating the os and cervix, so as to get an exposure through 
them. This may be done to almost any extent with compressed 
sponge. After this exposure is ample, we may attack the tumor 
through the cervix. 

It is always desirable to have the patient in as good a state of 
health as possible, and perhaps this is all that is needed, but it is 



TUMORS OF THE UTERUS. 393 

now becoming a point with some very capable surgeons to create 
a special diathesis as nearly as they can to insure plastic inflam- 
mation afterwards. They give the muriated tincture of iron and 
liberal diet for several days beforehand with this view. The ope- 
rations now advised and practised are, 1st, enucleation (or extirpa- 
tion) ; 2d, exciting destructive inflammation in the tumor ; or 3d, 
a combination of these two. 

For the performance of enucleation, the patient may be placed 
on the left side, with the hips elevated, before a large window. 
The vagina may be dilated with Sims's duck-bill speculum. "When 
the tumor is well exposed. — if the upper part of the vagina is 
developed so as to allow the tumor with the posterior or anterior 
wall of the uterus to enter it, — we may make a crucial incision as 
large as we can without wounding any of the pelvic viscera, and 
deep enough to lay open the cyst or external envelope. Half 
an inch is generally deep enough. "We may then withdraw the 
dilator, and introduce our finger so as to separate the tumor from 
the wall of its envelope as far as we can reach. This being done, 
the tumor should be seized by a vulsel forceps, and drawn down 
toward the vulva as far as possible with one hand, while with one 
or two fingers of the other we should extend the separation or 
enucleation of the tumor from the cyst or sac in which it is con- 
tained. Operating in this way, we may sometimes succeed in di- 
rectlv enucleating and removing the whole mass. We have an ac- 
count of a very interesting case in which this operation succeeded 
by Dr. B. Fordyce Barker. Operations of this kind are not always 
so simple as this description would seem to indicate, and much 
must be left to the discretion and ingenuity of the operator in con- 
triving the instruments and mode of performing them. When the 
tumor cannot be thus wholly enucleated, as much should be dragged 
down and removed as practicable, without too much damage to the 
uterus and danger to the surrounding organs ; and then the wound 
stuffed with lint or other tent until inflammation is established in 
the mass of the tumor. This will probably not require more than 
twenty-four or thirty-six hours. The tent or lint must then be 
removed, and the uterus kept under the influence of ergot for 
several days. Sometimes the tumor inflames and sloughs or sup- 
purates away, and disappears. This process may be accomplished 
in a few days, being much accelerated by the expulsive efforts 



394 TUMORS OF THE UTERUS. 

awakened in the uterus by the ergot, or it may require weeks for 
its completion. In this last case the patient suffers much from the 
hectic, toxgemic, or inflammatory symptoms which arise ; and in 
not a few the exhaustion overcomes the powers of nature, and she 
succumbs ; or she is overwhelmed in the excessive and wide-spread- 
ing inflammation of neighboring organs. 

Mr. I. Baker Brown, the learned and ingenious author of the 
Surgery of Women, operates a little differently. After dilating the 
vagina when necessary with elastic bags filled with air or hair, 
used for several days previous to operating, and exposing the tumor 
as extensively as possible by means of the duck-bill speculum or 
elevator, he draws the cervix down with vulsel forceps so as to get it 
completely in view. The preliminary operation, as he terms it, is 
then performed, which consists in making two or three incisions, 
so as to split up the cervix in as many places, completely to the 
envelope of the tumor. This operation may be best and most 
handily performed by a pair of long, curved scissors, with one blade 
thin enough to enter the cavity of the dilated cervix. In order 
to prevent the adhesion of the cut surfaces, and avoid dangerous 
or inconvenient hemorrhage, Mr. Brown directs that pledgets of 
lint, well oiled, be placed deep in the incisions, one upon another, 
until thoroughly filled, and to tampon the vagina with larger pieces. 
The tampon may be removed at the end of twenty-four hours, 
and the vagina well cleansed by injections of soap and water. 
The incisions, I think, may be kept open by passing the finger 
through them once a day, as well as by further using the lint 
tampon. This is what Mr. Brown calls his preparatory operation, 
and the essential parts consist, as may be seen, in removing the 
constricted condition of the vagina by gradual dilatation, and the 
cervix uteri by freely splitting it up. Nothing further is attempted 
until the results of this procedure are fully realized. Mr. Brown 
assures us that in many of the cases the dangerous hemorrhage is 
entirely cured, and the development of the tumor arrested. He 
records the results of fourteen cases occurring in the London Sur- 
gical Home. In ten the hemorrhage was cured ; in one it was re- 
lieved. In six cases the tumor had entirely disappeared or mate- 
rially decreased. When none of these results are realized, or but 
partially, and further operative procedure is necessary or desir- 
able, and after the cut edges of the incisions have cicatrized, Mr. 



TUMORS OF THE UTERUS. 395 

Brown pierces the tumor towards its centre, and by turning the 
knife takes out a piece of the tumor, much like coring an apple. 
He then plugs the vagina with oiled lint, to avoid alarming hemor- 
rhage. The coring part of Mr. Brown's operation is not so easily 
performed with the neatness that his simile would lead us to sup- 
pose, but we can almost always break down a portion of the tumor 
within the capsule, and thus cause its dissolution and elimination. 

Keasoning from the same basis of Mr. Brown, I have operated 
in two instances upon these fibrous tumors with success, in a 
manner, I think, more simple and easy of performance, and, con- 
sequently, more likely to be adopted by the general practitioner. 
The operation is done in the following manner : After having ex- 
posed the parts and isolated the tumor, by introducing a catheter 
into the bladder and a probe into the cavity of the uterus, if the 
tumor is in the anterior wall, or the finger in the rectum and the 
probe into the uterus, if the tumor is in the posterior wall, and 
thus exactly learning its relationship, we plunge a large-sized tro- 
car into the centre of the tumor, withdraw the stylet, and then 
push up through the canula as large a dossil of cotton or lint, with 
thread tied to it, as will pass it. We hold the cotton in the wound 
by a probe through the canula until this last is withdrawn. The 
cotton is thus left in the central part of the tumor, while the string 
or thread, which ought to be large and strong, keeps up a commu- 
nication with the vagina. Any blood effused passes readily out at 
this opening, and when the purulent or ichorous discharge of the 
tumor begins to be produced, it finds its way out along the string. 
This is really forming a fistulous opening into the tumor, after ex- 
citing inflammation in its centre. Should great inflammation re- 
sult, we may withdraw the cotton by pulling upon the string, and 
thus remove one source of irritation. Should there not be inflam- 
mation enough to disorganize the growth, a second operation may 
be performed, or at the first operation we may puncture the tumor 
in more than one place, and thus have two points of irritation. It 
will be seen that the operation may be easily varied by saturating 
the cotton with some irritating or caustic liquor, by using com- 
pressed sponge instead of cotton or lint, &c. I subjoin one of my 
cases as illustrative of the operation, &c. : 

Miss E , aged 29 years, has been subject to severe hemor- 
rhage at menstrual periods, and for two years they have been 



396 TUMORS OF THE UTERUS. 

alarmingly copious. She has become very much debilitated and 
nervous. An examination revealed an intramural fibrous tumor 
occupying the anterior portion of the uterus, apparently about 
the size of a hen's egg. It was quite low, so as to encroach 
upon the vaginal portion of the cervix. After sounding the 
bladder and uterus together, and learning something of the thick- 
ness of the tumor, I pushed a small-sized trocar up an inch or 
more into the interior of the tumor, and through the canula the 
cotton, with the thread tied to it. I left the cotton in place, and 
withdrew the canula. In about four hours the patient became 
alarmed, and sent for me on account of some hemorrhage. It was 
very slight, however, and was not sufficient cause for interference, 
but to allay her anxiety I introduced some more cotton by means 
of a probe into the track of the trocar. Nothing further occurred 
worth noting until the fourth day, when the patient became 
slightly feverish, and complained of pain and heat in the pelvis. 
There wer.e thirst, dry tongue, nausea, and heat of the surface. 
The pulse was about one hundred to the minute, and rather sharp. 
A moderate degree of fever kept up for ten days or two weeks, 
with varying degrees of intensity. About the sixth day after the 
cotton was introduced, a sero-purulent discharge made its appear- 
ance. It became more copious and grew offensive, and the tenth 
day some of the cotton passed away. The offensive discharge and 
feverishness, with copious perspiration and some diarrhoea, con- 
tinued for four or five weeks. After this they both subsided. The 
treatment consisted almost wholly of tepid water injections in the 
vagina, with a little soap in the water, three times a day, the solu- 
tion of the sul. quin. in some acidulated water, an occasional opiate 
at bedtime, and laxatives when needed for the constipated state of 
the bowels. 

Mr. Brown's preliminary operation may or may not precede my 
operation. The two patients upon whom I have operated have 
both recovered their health since the operation. This operation 
is left in the hands of the profession for future trial and adoption 
or rejection. 

Dr. Simpson, of Edinburgh, has, in at least one instance, effected 
the destruction of one of these tumors by cauterizing its interior 
with potassa fusa. While he guarded the vagina and other parts 
from the effects of the caustic, he held it in contact with the 



TUMORS OF THE UTERUS. 397 

tumor until it was penetrated to some extent by the caustic. In 
a few days the tumor was found to be in a state ,of inflammation, 
which quickly passed into gangrene and suppuration, and the mass 
was expelled in shreds and half-broken-down pieces. The cure 
soon followed. 

Of all these modes of operating, that of enucleation, when prac- 
ticable, is most to be desired. It affords more promise of success 
on account of the less amount and of the shorter continuance of 
inflammation and fever. There are several things all-important 
to the safety of the patient, in the cases of suppuration and gan- 
grene resulting from partial enucleation or cauterization. I think 
one of these important matters is cleanliness, by frequent and co- 
pious injections of tepid soapsuds, nourishing diet, and tonic treat- 
ment, this last mergiDg into stimulants, as the depression becomes 
greater. But of course, the practitioner will be the best judge of 
the after-treatment, and will have obvious indications from the 
symptoms which may be present. I apprehend that as much if 
not more success in such operations will depend upon the judi- 
cious management of the patient during these exhausting processes 
of suppuration, gangrene, &c, than upon the skill with which the 
operation is performed. I have thought that all severe operations 
result more favorably in the country than in cities, and especially 
those in hospitals. 

Next in difficulty of management and cure to the intramural 
variety of fibrous tumors, is that variety of fibrous polypus which 
grows from the fundus of the uterus and extends down into the 
cavity of the body. One indispensable preparation to any opera- 
tion that may be considered desirable in these cases is the com- 
plete dilatation of the mouth of the womb. The dilatation should 
be so great as to admit a free use of any instrument we should 
desire to employ. This may be accomplished in two ways ; by 
slitting it up with scissors or a knife, and allowing its edges 
to cicatrize before proceeding further, or by introducing pre- 
pared sponge. If we dilate with a sponge we must introduce a 
piece every day large enough to fill up the os. When the parts 
are sufficiently dilated we may proceed to operate. There are 
several modes of operating for these polypi. The object should 
be to remove the whole mass when practicable. If the tumor is 
small, this may be done by torsion, or evulsion, both of which are 



398 TUMORS OF THE UTERUS. 

safe modes ; but if the neck is large and strong we cannot re- 
move it in this way without very greatly endangering the integ- 
rity of the uterus. In that case, if we can get the chain of the 
ecraseur around the neck we should remove it in that way. But, 
as I have sometimes experienced, this cannot always be done. 
When this is impossible, there are three other modes of proceed- 
ing. The first is to crush the growth as completely as may be 
done with strong forceps ; a large lithotomy forceps will do very 
well for some cases, or we may have a forceps made for the pur- 
pose. When crushed entirely up to the point of attachment, in- 
flammation and sloughing are soon followed by the expulsion of 
the mass, either piecemeal or wholly, and the patient recovers. 
Mr. I. Baker Brown recommends his operation of coring, that is, 
gouging out as much of the centre and as high up as possible, and 
then leaving the remainder to the powers of nature. The old- 
fashioned mode of operating by ligature is the most effectual in 
some specimens ; but as it is the most tedious, and probably also 
the most dangerous method, unless there are special reasons in its 
favor, I prefer one of the above as being easier performed, more 
expeditious, and as effective. We perform evulsion and torsion 
with strong vulsel forceps, twisting and drawing alternately. 

Torsion sometimes may be successfully applied to very large 
polypoid growths within the uterus. I recently met with a case 
where the polypus was attached high up the posterior wall of 
the uterus, almost as high as the fundus. It was very large, fill- 
ing up the vagina and pelvis quite completely. I attempted to 
draw it out with vulsel forceps, thinking that I might thus be able 
to bring the attachment under my sight, but this was found diffi- 
cult, and I introduced my hand by the side of the tumor, until I 
could measure the size and discover the position of the attachment. 
The neck appeared to be an inch and a half in diameter and quite 
short. With the hand thus introduced, I seized and rotated the 
polypus upon its axis several times, until I could feel that the at- 
tachment was entirely overcome and the tumor free in the vagina. 
In less than ten minutes from the time the hand was introduced, 
I drew the tumor out of the vulva. It weighed 32 oz. avoirdupois 
weight. There was not much hemorrhage, — perhaps not six ounces 
of blood was lost. The uterus was quite large, reaching up to the 
umbilicus, before the polypus was removed. In ten days the 



TUMORS OF THE UTERUS. 399 

patient went to her home in the country, and two months after 
appeared to be well in every respect. Now the uterus is but slightly 
larger than natural, and the hemorrhages, which were very exhaust- 
ing, have entirely ceased. I was prepared for hemorrhage in this 
case, but was glad to observe that it did not occur. 

The operation of ligating the neck of the tumor can be per- 
formed with a double canula, described by Gooch, and is so famil- 
iar to every student that I need not describe it. When any of 
the tedious processes are adopted, it will be best to wash out the 
vagina and uterus with a good syringe several times during the 
twenty-four hours, to prevent as nearly as possible — by dislodging 
them — the absorption of any of the noxious products of decompo- 
sition. "We should be aware of this danger, and guard against it 
by every available means. 

The fibrous polypi springing from the cervix, and occupying 
more or less completely the vagina, should never be ligated, crushed, 
or dealt with in any other than in a summary way. They should 
be immediately and completely removed. The preferable plan of 
removal, when small, is to seize them with a vulsel forceps, and 
twist them off. This mode, by torsion, almost always proves en- 
tirely successful when the polypus is not large. When the neck 
is so large that it cannot be twisted off, we should draw the tumor 
down with the forceps, until the attachment appears at the vulva, 
when the chain of the ecraseur should be thrown around it, and 
the connection severed with this instrument. This operation is 
simple, safe, and practicable. Nobody need fail in it, or fear any 
subsequent bad effects. But another equally simple and practica- 
ble, and almost as safe a method, is to divide the neck of the poly- 
pus close to the attachment with the scissors or knife. To do this 
handily, the polypus should be drawn down as before. 

In about two and a half per cent., hemorrhage is troublesome 
after cutting off with the knife, but it may be easily controlled by 
the tampon ; or what is the pleasanter way, to expose the part 
with a speculum, and apply the persulphate of iron to it. Some- 
times we find instances where a polypus has an attachment to the 
cervix by an ordinary neck, and on account of inflammation, con- 
tracts adhesions to the vaginal walls besides. These adhesions, so 
far as I am aware, are not very firm, and judging from a limited 
experience, may be overcome by the finger. 



400 TUMORS OF THE UTERUS. 

Whether this be the case or not, the neck of the growth may be 
exposed by traction, and severed as before, and these adhesions be 
overcome by the finger, the handle or blade of the scalpel, as may 
seem necessary. 

The soft variety of the polypus may be destroyed by torsion and 
evulsion always, so far as I am aware. The operation consists in 
seizing it with flat-bladed forceps and twisting it off. I have, on 
some occasions, taken it off with curved scissors, without any bad 
results, and with perfect success, so far as the ultimate cure was 
concerned. 

The removal of the fungous polypus is a more serious and diffi- 
cult operation. It is also much more uncertain in its results, in 
two respects. It is often reproduced in spite of all the care we 
can summon, and again produces malignant degeneration in the 
uterus and surrounding organs. In removing the other forms of 
growth, we are pretty sure of success if we remove nearly all the 
tumor, a small part of the neck disappearing spontaneously when 
left to itself. 

In the fungous or epitheliomatous growth, on the contrary, it is 
not only necessary to remove all the fungus, but to remove the 
tissue whence it springs. We should be so liberal in its removal 
and the seat of growth, as to include all the cervix that may 
be amputated without damage to other organs. There are two 
ways of doing this. In the first place, the cervix should be drawn 
down by means of strong hooked forceps, so as to show at the 
vulva as much as we 4esire to remove. After this exposure, we 
may surround the cervix with the ecraseur, or we may fairly cut 
through the sound tissue entirely above the disease. 

This is a serious and not always safe operation in its general re- 
sults, although simple, and may be easily performed. It is apt to 
be followed by inflammation of the uterus and peritoneum, and 
thereby endanger the life of the patient. Any bleeding that may 
occur, may be stopped, peradventure, with the persulphate of iron 
and the tampon. 



CHAPTEE XXVIII. 

OVARIAN TUMORS. 

Ovarian tumors spring from and are for the most part formed 
of the hypertrophied tissues of the ovaries. There are tumors 
very much resembling and often mistaken for them, however, de- 
veloped in the lateral ligaments. These latter are generally dis- 
tended and hypertrophied sacs of the parovarium, and contain 
thin serum, merely ; are cured sometimes by tapping, or they spon- 
taneously burst, or are broken by accident in the peritoneal cav- 
ity, and disappear, never again to annoy the patient. The Fallo- 
pian tubes sometimes are the seat of enlargement. The tubal 
canal becomes obliterated at each end, and fills up with the hilus 
usually appropriated to the lubrication of its inner surface, hyper- 
trophies in tissue, and thus constitute a morbid development. 
Although rare, these two forms of tumors are observed. Doubt- 
less, other enlargements, of a nature not yet properly understood, 
are sometimes originated by unknown causes. The anatomical 
distinctions can be made in most instances by careful dissec- 
tion, so that in cadaverous investigation they need not be con- 
founded with the ovarian tumors, except it be where all tissual 
distinctions are obliterated by an intercurrent or supernatant 
disease. It is not my purpose now to pursue this subject fur- 
ther than the mere mention here made. In the proper ovarian 
tumors, we may trace three coats or layers of tissue forming their 
walls. The external is the serous or peritoneal. It is shining 
and smooth as this membrane is elsewhere, and seldom changed 
in any way, except it may be thickened and hypertrophied. It 
can be traced into the peritoneal covering of the viscera and ab- 
dominal parietes, and consequently needs no elaborate description. 
The internal coat or lining membrane, is doubtless the membrana 
granulosa of the ovisac, very much hypertrophied. When small, 
something like epithelium seems to be its entire composition. As 
they grow and develop, the epithelial arrangement is less perfect, 

26 



402 OVARIAN TUMORS. 

until, when very large, we can observe it only in patches. In 
many cases when thus large, this membrane has a smooth, lus- 
trous appearance, but in others, it is more or less thickly studded 
with granular projections, varying from almost imperceptible mi- 
nuteness, to the size of peas, or even larger. Regarding the main 
sac as an hypertrophied ovisac, I think these little granular sacs 
(for they prove to be sacs upon examination), are also of the same 
nature, and are the origin of the numerous endogenous or supple- 
mentary growths which constitute one of the polycystic varieties. 
The middle coat is made up from the stroma of the ovary. Its 
strength depends upon quite a considerable amount of fibres, which 
enter into its composition. As the tumor develops, these fibres 
are enlarged, and apparently, if not really, increase in numbers, 
until they constitute the most of the thickness of the walls, and 
in some parts make quite a thickness, density, and toughness of 
tissue. These qualities are greater in old large sacs than in the 
smaller and younger ones. At the pedicle and for some distance 
up the sides, they are greater than in other portions, being in 
these parts sometimes a quarter of an inch thick, while at the fun- 
dus or distal portion, they may be thin and fragile. The whole 
of this coat may be very tough and thick, so as to resist great 
force, or it may be thin throughout, so as to be easily ruptured at 
almost any point. Entangled in the meshes of these fibres may 
be discovered, in many cases, the minute microscope points so 
numerously scattered through the substance of the ovaria. These 
points are believed to be the origin of the germinal spot in the 
ovum by some physiologists, and around which are developed the 
ovum and progressively the whole ovisacs and their contents ; and 
I believe that their presence in the walls of the tumors, over much 
if not the whole of their extent, accounts for the development of 
the minute granular internal projections above described. In a 
tumor recently removed from the body, by holding it up to the 
light we may not unfrequently discover the peculiar buify tinge 
seen in the stroma. The vessels are situated in this coat. They 
are numerous and some of them large, so large that great care is 
necessary to prevent them from bleeding when the peduncle is 
divided. They are developed, it is hardly necessary to say, to 
this great size, from the minute twigs which penetrate the sub- 
stance of the ovary. 



OVARIAN TUMORS. 403 

The shape of ovarian tumors may vary much. They may be 
regularly globular, polyglobular, angular, or irregular in almost 
every way. When small, the ovary may be seen as constituting 
a considerable portion of the tumor. When large, the ovary may 
be almost lost in the walls, or observed as a mere tubercle stick- 
ing to or imbedded in its side. Yet generally but one ovary 
is the seat of disease, but in a few instances both are affected. 
Not often do they become consecutively the nidus of these 
growths ; one being first the subject of disease, and then followed 
by the other. And when such is the case, we are not warranted 
in supposing the one to be the cause of the other, either remotely 
or directly. Notwithstanding the above assertion, I do not wish 
to be understood to say, that sympathetic degeneration between 
these two bodies is impossible. These tumors divide themselves 
anatomically into monocystic and polycystic, — the one having a 
single cystic cavity, the other several. The polycystic variety is 
formed by the development of several cysts adjoining or by the 
side of each other, and independently attached to or springing 
from each other on the external surface, or within the cavity of 
one large one. The instances of polycysts growing by the side 
of each other, and being independently attached, resembles at 
first the single. At an early stage of development they may 
stand free of contact one with the other, but as they grow in 
size, in consequence of the small, surface of the ovary to which 
they are attached, they crowd together, so that it is not always 
easy to say whether they were not developed from each other. 
The cysts from which smaller ones grow, are called proliferous. 
They are doubtless single for some time in their early develop- 
ment, but carrying up, as they increase in size, the proper sub- 
stance of the ovary, with its rudimentary ovisacs, after a while 
the inner or outer surface is bulged by the maturity of these last, 
which, if they do not dehisce and allow the escape of the ovum, 
grow into a subordinate tumor. This process is separate, until 
there is a glomeration of cysts to quite a number, from four to 
fifty, of various sizes, — from the size of a man's head, down to 
that of a pin's head. Small ones may be so numerous as to stud 
a large part of the inner surface with granulated elevations. This 
is the most frequent variety met with in practice. 

There is a great difference in the sensible qualities of the con- 



404 OVARIAN TUMORS. 

tents of the cysts in different cases, and of the different cysts in 
the same case. In some, it is very thin, in others, very thick 
and tenacious, while the color shades from black, inky, to limpid 
clearness. The monocystic, as a general thing, affords thinner, 
clearer fluid than the polycystic, though this is not invariably so. 
It is in the monocystic variety, however, that we generally find 
the solid contents. These solid contents are, for the most part, 
formed of tegumentary, adipose, hairy, osseous, and dental tissues. 
All these are irregularly developed and distributed, so that no 
semblance in shape or other conditions can be discovered to an 
independent being, — as a foetus. Sometimes the tegumentary 
substance is small and gives attachment to a few hairs ; sometimes 
the quantity of hair is long and entirely isolated, and either in- 
extricably knotted together, or straight and few in number. They 
may be long — ten or twelve inches — or very short. Irregular 
bones, or the enamel of teeth, without the bony structures, are 
often attached to the side of the cavity ; but no organic order, 
symmetry, or completeness, has yet been seen. In fact, should a 
femur, a scapula, a complete maxilla, or other complete organ, be 
developed, the tumor would range itself under the head of extra- 
uterine foetation, and not ovarian disease proper. The tumor 
containing solid materials of this kind is usually small. Not un- 
frequently large fibroid growths are observed in the ovary at the 
base of a single or multiple cystic tumor. These solid fibroid or 
fibrous growths may be simple or benign in their nature, or ma- 
lignant. This complication of ovarian dropsy I think more fre- 
quent in persons advanced in years — over forty — than younger 
ones. The contained fluid of the polycystic tumor is ordinarily 
highly albuminous, of high specific gravity, tenacious, and more 
or less colored. The fluid is so thick sometimes, as not to flow 
through a small canula. Blood and pus are the coloring matters 
of this fluid ordinarily. From one tumor of several cysts, I drew 
pus from one cyst ; dark coffee-grounds sanguineo-serous fluid from 
another ; a beautiful straw color from another ; and lastly, from an- 
other, fluid of a delicate azure tint. After tapping, more or less 
alteration is observed in the fluid, each operation withdrawing 
fluid affected by chemical or pathological circumstances. In the 
former, putridity or acridity would result ; in the latter, the puru- 
lent productions of inflammation might be expected, or fibrous 



OVARIAN TUMORS. 405 

concretions, or serum, changing the tenacity and thickness of the 
fluid. 

There are some chemical and microscopic resemblances in the 
fluid from almost all varieties of ovarian tumor. Albumen seems 
to be almost always present. In some specimens of fluid, strong 
acids, or heat, causes it to assume a solid form, coagulating and 
adhering like the white of an egg when cooked in boiling water ; 
in others a small precipitate is all that is observed. Between these 
extremes all shades of difference exist, but undoubtedly, nearly 
all ovarian tumors yield highly albuminous fluid. The reaction is 
alkaline. Mr. Nunn says that, " As the results of many examina- 
tions (microscopic) of different specimens of ovarian fluid, the most 
constant characteristic of such fluid is its containing, in greater or 
less abundance, cells gorged with granules ; and, in addition, cir- 
cumambient granules, having the same measurement, encompassed 
by the cell. The size of the gorged cells and included granules 
varies greatly, even in fluid from different cysts in the same ovary." 
This description of fluid could, with certainty, remain good of the 
first evacuation only, as pus- and blood-globules are not unfre- 
quently found in subsequent evacuations. 

I have already stated what I believe to be the nature of the 
sacs or cysts of ovarian tumors, and it will not be necessary to 
repeat it ; but there is one curious question, as to the origin of the 
solid substances sometimes found in them, which so very much re- 
semble the tissues of a foetus, upon which I feel at liberty to add 
my conjectures to those of many others who have written upon 
ovarian disease. I do not desire to argue elaborately in favor of 
the opinion I embrace, or against those who adopt a different one, 
nor to give instances to any extent in proof for or against. I do 
not think that the discovery of hair, fat, teguments, bone, or teeth 
in the ovary, in the imperfect state of development and irregular 
relationship above described, affords any evidence of impregnation 
or sexual connection. In explanation of the formation of these 
tissues, it may be conjectured that the ovaria have such independent 
cell capacities as will enable them not to form a living being inde- 
pendent of sexual influence, but under certain circumstances to 
imperfectly produce tissues of a very elementary nature, resem- 
bling those found in the products of impregnation. The tissues of 
ovarian disease are of the lower grade in a formative sense. We 



406 OVARIAN TUMORS. 

do not find muscle, nerve, or vessel in these places and under these 
circumstances. There does not seem to be generic energy enough 
in the ovum, unaided by seminal impression, to give the direction 
to cell action for the formation of these more complicated tissues. 
We should observe, too, that although the cell action of the ovum 
may start up the formation of these singular tissues, there is no 
generic order or completeness in that action. In all this we see 
another of nature's distinct modes of formation under peculiar cir- 
cumstances. I am not aware that in any other part of the body 
such a condition of development ever takes place inside of a cyst, — 
a development which gives origin to so irregular an assemblage of 
tissues without the formation of any organ out of them. When 
foetal tissues are found elsewhere in the body, or in any part of 
the male, there is something of organic completeness about them, 
and perfect bone, tooth, or some or many organs may be distinctly 
traced. Nerve-matter, muscle, &c, and, in fact, all the more com- 
plicated tissues are met with. These facts, I think, establish a 
broad difference between the products of conception and the ir- 
regular cell or tissual development'of the ovum, and I cannot see 
why the theory I have mentioned may not explain all the circum- 
stances fully. 

I have not much doubt that the state of the ovaries has much to 
do in starting up these tumors, and it is most likely that inflam- 
matory thickening or condensation of the peritoneal or fibrous en- 
velopes of this organ is the condition. If we imagine the fibrous 
indusium to be thickened and condensed, so as to be less fragile 
or less amenable to the influence of the absorbents, and failing to 
yield to the distension of the maturing organ so confine it that the 
follicular fluid cannot escape, we have incipient ovarian dropsy. 

It is only necessary that the unruptured coats of the ovisac 
should continue to secrete its fluid, and the strong indusium refuse 
to crack open and allow its escape, to have all the conditions of an 
ovarian dropsy, that will be limited only by circumstances foreign 
to those of their origin. However this may be, there can be no 
question but that the beginning is the failure to discharge the fluid 
of the ovisac, and that this last is, in the early stages, the fluid of 
the ovarian tumor. There is, also, a kind of independent pathology 
of ovarian tumors. After they are developed to a certain extent, 
they become subject to accidents and disease, and play an impor- 



OVARIAN TUMORS. 407 

tant part, in consequence of this fact, in the sanitary conditions 
of patients in whom they exist. Inflammation, for instance, at- 
tacks them, and causes ulceration in their walls so as even to per- 
forate them, making a communication between the cavities of con- 
tiguous cysts, or with the peritoneal cavity. Without perforating 
the walls of the tumor, the ulceration may produce a good deal of 
pus, which is mingled with the other contents of the cyst in which 
it occurs. General inflammation of its walls may proceed to a 
fatally exhaustive extent, or spread to the peritoneum, and thus 
indirectly cause death. Gangrene may also result, which may be 
confined to the cavity of some of the cysts, and induce a putrid, 
offensive state of the contents, or perforate the dividing partitions, 
and thus make a communication between cysts, or open them into 
the peritoneal cavity. The walls may also rupture from distension 
in consequence of their becoming attenuated, or by a violent stroke 
or fall, or other shock, the tumor may be ruptured, and the con- 
tents escape into the peritoneal cavity. By means of ulcerative 
communication with the Fallopian tubes, evacuation of the fluid 
occurs. Adhesion to the walls from inflammation and ulceration 
through the parts thus agglomerated sometimes results, and the 
fluid so discharged. Inflammation also causes adhesion at various 
parts. The fibrine effused glues it to the surrounding parts, — the 
abdominal walls, the intestinal canal, bladder, and other viscera. 
Slight inflammation is supposed to increase the effusion in their 
cavities, and cause them to grow very rapidly. Inflammation, 
also, sometimes, no doubt, causes obliteration of the cavity from 
adhesion of the walls. This is more frequently the case when it 
results from external causes, as blows, tapping, pressure, injec- 
tion, &c. Now, it hardly ever happens that these diseased condi- 
tions and accidents of the tumors fail to produce their effects upon 
the health of the patient. No doubt but that death occurs from 
extensive disease in the sac, without any organ being involved in 
the trouble directly. A large production of pus would exhaust the 
patient ; gangrene, to a large extent, would cause death, as exten- 
sive gangrene of unimportant organs generally does. But an ex- 
tension of disease to the peritoneum and surrounding viscera, or 
by the effusion of the acrid contents of a diseased cyst, is more 
likely to be the mode of progress to constitutional disturbances in- 
augurated by inflammation in the tumors. When the tumor bursts, 



408 OVARIAN TUMORS. 

and its contents are effused into the peritoneal cavity, the peri- 
toneum seldom escapes without inflammation ; but the degree will 
depend upon the nature of its contents. If they are not vitiated, 
but consist of the bland albuminous fluid found there ordinarily, 
it is very slight indeed, and lasts for a very short time only. But 
should pus, or the ichor of decomposition, be mingled with it, we 
should be prepared to expect serious if not fatal results. 

I once had an opportunity of observing the progress of a case 
for several months, w T here this rupture and effusion were frequently 
repeated. About every three weeks the woman would attain to a 
large size, and a well-defined, large cyst could be felt filling up 
the whole abdomen and distending it greatly ; when suddenly, with- 
out premonition or apparent cause, the cyst would give way, the 
swelling would become more diffuse, fluctuation very evident, and 
the cyst could be no longer defined by the touch ; slight fever and 
some tenderness of the abdomen would last for two or three days, 
when copious perspiration and diuresis would evacuate the fluid in 
a few days more. After this process was completed, the abdomen 
would be lank, and a small cyst could be felt rising up from the 
left ilium ; it would increase and burst at the end of three weeks, 
as the other had done before. I saw the patient frequently while 
this process was repeated six or seven times, when, as she would 
not submit to the operative procedure which I insisted upon, I was 
dismissed, and an irregular practitioner, who was sure he could 
cure her, installed in my place. Not long (perhaps three months) 
after I was discharged she died from the inflammation resulting 
from one of these effusions, probably because the contents of the 
cyst had become vitiated by inflammation within its cavity. 

But these growths may produce a pathological condition of the 
system, without becoming themselves the seat of disease, by the 
great size they may attain, mechanically interfering with the func- 
tions of the pelvic and abdominal viscera. Before rising out of 
the pelvis it may displace the uterus, and cause inconvenience from 
this effect ; it may press upon and obstruct the rectum, bladder,, 
and urethra, or upon the iliac veins, causing obstruction to the 
flow of blood, and varicose veins in the legs, phlebitis or phlegma- 
sia dolens ; or, pressing upon the nerves, cause neuralgic pains in 
the limbs, hips, &c. It is plain that such pathological effects, 
when induced, would be serious, in proportion with the greater or 



OVARIAN TUMORS. 409 

less impaction in the pelvis by its continued growth. Ordinarily, 
these inconveniences do not prove very embarrassing to the func- 
tions of the important vital organs, but sometimes the case is far 
otherwise, and life is very much shortened and health rendered 
miserable. As it rises into the abdomen, these mechanical troubles 
are apt to be lessened ; and as the room is comparatively so great 
in that cavity, quite a while elapses before any great disturbance 
results from mechanical pressure. After awhile, however, the 
abdominal muscles are distended beyond convenient size, and the 
tumor is strongly pressed among the viscera. The kidneys, liver, 
stomach, intestinal tube, in fact, all the abdominal organs may be- 
come the subject of great and even fatal pressure. In many in- 
stances, however, enormous size is attained before fatal damage 
results. One hundred and fifty pints of fluid have been taken at 
a single tapping. A much less amount, in most cases, would pro- 
duce very grave results by pressure. When the growth is rapid, 
its mechanical effects will be more distressing; and, on the con- 
trary, the organs accommodate themselves to a great deal more 
pressure if gradually brought about. 

Besides the inflammatory changes that take place in the tumor, 
chronic degeneration is occasionally observed. Deposits of earthy 
substances in the walls, bony spiculse, &c, are the most frequent. 
Small tumors, containing solid material, are more commonly thus 
affected. 

The modes of termination are worthy of some consideration. 
Many cases last through a great many years without materially 
influencing the general health, and up to the death of the patient, 
at an advanced age, prove to be nothing more than an inconve- 
nient burden when large, and when small not the cause of even 
this kind of trouble. But cases of this class are not very numerous, 
and by a large majority they terminate, and leave the patient in 
the enjoyment of real or comparatively good health, or by their 
effect upon the constitution shorten her existence. Spontaneously 
favorable terminations are so rare that we can base no calculation 
upon them ; but were it possible, it would be interesting to follow 
nature through her resources in this respect ; and I am sorry that 
my means for reference are so limited as to prevent me from 
thoroughly examining this branch of the subject. Perhaps rup- 
ture of the sac into the peritoneal cavity, collapse and adhesion of 



410 OVARIAN TUMORS. 

its walls, is the most common and favorable spontaneous termina- 
tion. After the rupture, in cases where cure follows, it is probable 
that the opening in the sac continues, and that a permanent fistula, 
so to speak, from the cyst into the peritoneum, places the fluid in 
contact with a more active absorbing surface, until, by the elasti- 
city of its walls, it contracts to annihilation, or, at the first shock 
of the rupture, inflammation is originated that causes an oblitera- 
tion of the cavity of the sac. Dr. Simpson speaks of instances of 
evacuation through the vagina. The same thing might occur in 
connection with the bladder or alimentary canal. I have already 
spoken of adhesion to and rupture through the walls of the ab- 
domen, and consequent recovery. Inflammation in its proper tis- 
sues, no doubt, sometimes arrests the development of and obliter- 
ates the tumor without materially affecting the patient's general 
health. It is not improbable that other circumstances with which 
we are not acquainted may likewise operate to cause the arrest and 
cure of them, inasmuch as they unquestionably do sometimes dis- 
appear in an unaccountable manner. 

The local pressure interfering with the functions of the bladder 
and rectum may induce complicating diseases that lead to death, 
and consequently cause death before the tumor is very largely de- 
veloped. Inflammation will spread upon these organs to their more 
vital connections and relative organs ; or, by interfering with ex- 
cretion from the bowels or bladder, produce disease of the blood, 
and thus gradually undermine the health of the patient. 

After the tumor has arrived into and greatly distended the ab- 
dominal cavity, pressure upon the viscera will sometimes produce 
disastrous terminations. The stomach is crowded into a very small 
space, and food can be taken but sparingly, and is often rejected 
before digestion is completed. The vascular supply of this organ 
is cramped, and its secretions vitiated and embarrassed, and in this 
way digestion is interfered with, the appetite destroyed, and loath- 
ing of food takes its place. 

Pressure upon the vena porta embarrasses the secretion of the 
liver. Pressure upon the ductus choledochus, gall-bladder, and 
duodenum, stops the excretion of bile; it is dammed back upon 
the gland, absorbed, and thrown into the blood to poison the 
nervous centres. 

There is no doubt, also, that the general compression of the 



OVARIAN TUMORS. 411 

organs, by pressure upon the chyle absorbents, prevents that fluid 
from passing as freely as usual into the blood, and thus by degrees 
starves the patient. But probably no more disastrous effects of the 
pressure of the tumor in the abdomen is noticed, than such as is 
produced through the kidneys. Pressure upon the emulgent veins 
causes congestion of the kidney tissues, retention of urea, and 
other matters that should be excreted, and drains off the albumen 
with the urine, until the blood becomes thinned enough to infiltrate 
into the cellular tissue, generally in the form of oedema of the ex- 
tremities, or into the peritoneal cavity, giving rise to ascites. But 
this is not the worst mischief, perhaps, caused by the pressure on 
the kidneys. The poisoning of the blood with urea, and its effect 
on the nerves and vital organs, is too well known to require more 
than mere mention to suggest the rapidly fatal tendencies which 
result from it. 

Inflammation in any of the important abdominal organs may be 
caused by the pressure, which will terminate fatally in a greater 
or less time, owing to its acuteness or slowness of progress. It 
will be seen by the above very short description that ovarian dis- 
ease usually terminates by inducing a long train of distressing 
constitutional symptoms. They are not uniform in different cases, 
some persons suffering from one mode of complication and some 
from another ; but nearly all are pretty sure to experience those 
terrible sufferings which are connected with secondary disturbances 
in the vital organs. 

The presence of the tumor, when not large enough to press upon 
the organs sufficiently to do very much damage, sometimes leads 
to copious dropsical effusion in the peritoneal cavity. This is, at 
least sometimes, the result of an influence exerted upon the peri- 
toneum, causing it to secrete more than an ordinary amount of 
serum. 

One case upon which I operated and evacuated a large amount 
of serum from the peritoneal sac, recovered completely from the 
operation, but died about two months after from extreme abdom- 
inal distension, in spite of alteratives and diuretics. 

Causes. — It is extremely doubtful whether there is anything in 
the general condition of the patients that predisposes to the de- 
velopment of ovarian tumors. There is quite a disposition, how- 
ever, with certain authors, as will be apparent to any careful 



412 OVARIAN TUMORS. 

reader, to trace most chronic enlargements to scrofulous taint in 
the system ; and these gentlemen express the belief that scrofula 
predisposes to ovarian disease. The term of life during which 
menstrual influences are exerted upon the general organization, is 
very much more frequently the time when it is most active ; so 
that we may very safely conclude that in the function of menstru- 
ation we have a predisposing cause of ovarian disease. It is true 
that ovarian tumors have been found in the ovaria of infants and 
foeti, and originating in very aged females ; but this probably is as 
rare an exception to the general rule, that they occur during men- 
strual life, as the occurrence of menstruation in infancy and old 
age is to the general rule that this takes place at the usual time. 
And probably, too, a careful examination of the anatomy of these 
exceptional cases will prove them to be as exceptional in nature 
to the ordinary ovarian tumor, as the time in which they occur 
would seem to indicate. Some circumstances connected with men- 
strual life appear also to increase the predisposition. Sixty-one 
per cent., according to Dr. West, of the patients were married, 
while only twenty-nine had never been married. After making 
allowances for the greater proportion of women at twenty-five 
who are married, I think we may fairly infer that marriage adds 
somewhat to the chances of the occurrence of ovarian dropsy. 

That patients who are the subjects of this disease should be less 
likely to have children than those in whom ovulation is more per- 
fect and complete, will not, I think, justify us in setting down ster- 
ility as the cause of it in any way, but it is more probably con- 
nected as an effect. During menstrual life, the most obnoxious 
time is between the ages of twenty-five and forty, the time when 
the sexual functions are exercised with more activity than any 
other ; so that it would be right to say that menstruation and 
marriage both predispose to ovarian disease. 

Unhealthy menstruation seems to be more commonly coincident 
with it than healthy. Abortions and premature labor are so, 
likewise. 

We should attach sufficient importance to the fact that it occurs 
in unmarried persons as often as twenty-nine per cent. This in- 
duces Dr. West to remark, that " it occurs in the unmarried oft- 
ener than any other organic disease of the sexual organs." 

The exciting or proximate causes are such as excite the ovaria 



OVARIAN TUMORS. 413 

and induce abortive efforts at ovulation. What does so, we are not 
able to say with certainty; but we can say what might and conse- 
quently, probably does, produce this effect. 

Inflammation of a low grade and somewhat chronic duration, 
might cause induration or thickening of the indusium, so that it 
w r ould not yield to the upheaving pressure of the ovisac, so as to 
burst or become absorbed and permit dehiscence, or the peripheral 
portion of the proper substance of the ovary might be condensed 
by it, and thus rendered unfit for a covering for the tumor. 

The probabilities, I think, are quite in favor of this mode of 
initiating these morbid growths, or merging a healthy into an un- 
healthy accumulation. When once thus commenced, the stimulus 
of increased incretion of fluid would carry on a kind of hyper- 
trophy in the involucra that would permit of a further enlarge- 
ment. Now the local circumstances that are regarded as the 
causes of the disease, would favor the occurrence of inflamma- 
tion, and are very frequently attended with some of the symptoms 
of it. The local condition of the ovary and uterus, during each 
menstrual period, is often attended with pain in the ovarian region 
of just such a character as we would expect to indicate inflamma- 
tion. This ovarian pain is present in other excited conditions of 
the sexual organs also, thus showing that they are often the focus 
of painful vascular turgescence, if not inflammation. How easy 
it is to conceive the possibility, nay the probability, of nutritional 
vitiation to an extent sufficient to prevent dehiscence of the ovum 
after it is matured in the ovisac. If this state of things may 
take place in consequence of menstrual congestion, or congestions 
from other transient or mild causes, how much more likely is it to 
be induced by the inflammations which succeed to abortions or 
parturitions. While inflammation is probably the cause of the 
beginning of the development of ovarian tumors, it does not seem 
necessary to their continued development, as the accumulation of 
fluid in a shut cavity with a secreting internal surface is a matter 
of course, and the limit of its amount, for the most part, does not 
depend upon anything but the capacity of the involucra to grow, 
which they usually do until interrupted by external circumstances. 

Although inflammation may, in most cases, be the cause of the 
toughness of the covering to the ovary, which prevents the escape 
of the ovum, this condition may result from some other local cir- 



414 OVARIAN TUMORS. 

cumstances. Congenital formation may be such as to give rise to 
this difficulty. — possibly, may allow development of the ovisac ; 
may allow the involucra to increase as fast as the demand for more 
room becomes necessary. 

Prognosis. — Our knowledge with regard to the prognosis is un- 
fortunately too definite. There is no need of much conjecture 
with reference to this matter : the termination is too frequently 
demonstrated. In arriving at prognosis with reference to any 
disease, we ought to consider whether its ordinary course is, after 
a time, to a termination in health, as is the case with many dis- 
eases, or, there being no such favorable tendency, what are the 
probabilities of a cure. Unfortunately, there is no tendency to 
spontaneous recovery, worth taking into consideration, in ovarian 
dropsy ; probably not two per cent, but would, after a longer or 
shorter time, terminate in the death of the patient. W hile this is 
the case, it does not properly represent the value of a life threat- 
ened by this affection. Some patients live a great many years in 
comparative comfort ; but, by large odds, the case is generally 
very different, — only a few years being sufficient to finish the 
course in a downward direction. The average duration of life is 
probably about three years from the time it is first perceived. So 
much difference of opinion exists among observers, and so unsatis- 
factory are the statistics, that the average number of recoveries 
under treatment is quite doubtful. The mortality, taken altogether, 
I should say, is not far from fifty per cent., — a fearful fatality ; 
and the average duration of life under treatment, and in sponta- 
neous cures, will not exceed very much, if at all, seven years. Yet, 
in selected cases, probably two-thirds of the patients may enjoy 
perfect health. Much of the mortality, in my estimation, depends 
upon the injudicious selection of cases for the different modes of 
treatment which have of late years proved successful. However 
discouraging the prognosis in general may appear in this kind 
of examination, we are not. justified in extinguishing the hope 
of our patient, by applying it to her case, without particular in- 
vestigation into the peculiarities of it. In fact, individual prog- 
nosis is too often left out of view, and general results are applied 
to individual cases. In certain instances, either too favorable or 
unfavorable an opinion is expressed, to the undue elation of our 
patient, or the perfect annihilation of all her hopes. All instances 



OVARIAN TUMORS. 415 

of the most unfavorable diseases are not to be unconditionally 
consigned to death ; nor every case of the more favorable classes 
of disease expected to terminate in health, without question. 

We should, therefore, carefully examine every individual case, 
with reference to its own peculiarities, its nature, and the charac- 
ter and condition of the patient. Is the disease simple, or a com- 
pound of cyst and solid, polycystic or monocystic ? The mono- 
cystic is very much more favorable for treatment, and terminates 
in spontaneous recovery oftener than the polycystic. The dura- 
tion of life is greater, also, in the monocystic. The cases in 
which there is no great amount of solid matter, are more favorable 
for treatment than those in which the solid is predominant ; but 
ordinarily, the more of solid material the less rapid the growth, 
and, consequently, the longer the duration of life in the absence 
of interference. How long has the tumor been in attaining the 
present size ? If several years have elapsed since the patient was 
aware of its presence, it will probably continue to increase slowly, 
unless, as is sometimes the case, more activity has lately been ob- 
served, and a tumor that had formerly grown very slowly, and re- 
quired a number of years to acquire half its size, has grown the 
rest in a few months. In this last, there is every probability of a 
rapidly fatal course. Again, if the patient has not known any in- 
crease of size until within a few months past, and yet is quite 
large, the prognosis is bad. Our prognosis is influenced by age 
to a considerable extent; occurring in young persons, it is more 
likely to advance rapidly, than in old ones. A woman at forty is 
not apt to develop an ovarian dropsy so rapidly as one at from 
sixteen to twenty. 

Ovarian dropsy will advance less rapidly after menstruation 
ceases than before, and the earlier in menstrual life, the more 
rapidly it will advance. The prognosis, as a general thing, there- 
fore, is worse in the young than the old. If we should decide the 
question how long will she live by age, we should speak more fa- 
vorably to the woman advanced in age. The fact, too, of the or- 
dinary chances for the length of life being in favor of the young, 
she is more likely to fall a victim to the advance of the disease 
than the older. We must take into consideration the circum- 
stances that complicate it in the last stages, when we examine 
particular instances. 



416 OVARIAN TUMORS. 

The inflammation, the pressure upon the rectum, bladder, stom- 
ach, bowels, and, above all, the kidneys, the nervous system, the 
vascular system, nutrition, as shown by the signs of emaciation or 
otherwise, should all be carefully scrutinized. . 

Diagnosis. — The diagnosis of ovarian tumors, when tolerably 
large, and not complicated with more than ordinarily embarrassing 
circumstances, is not difficult ; but instances do occur where the 
matter is far otherwise, and a positive opinion cannot, with pro- 
priety, be given. For the most part, the diagnosis is sought to be 
perfected with a view to treatment, and we ought not always to be 
too solicitous about exactitude in this respect, until the urgency 
of the case demands it for the sake of treatment. When it is de- 
sirable to inquire particularly into the diagnosis, as a general thing 
we wish to know, 1st. Whether the case under examination is an 
ovarian tumor; 2d. What sort it is, — solid, fluid, or mixed; 3d. 
If fluid, whether simple or multiple, — multilocular or unilocular, 
polycystic or monocystic ; 4th. Whether adherent or not. All 
these questions are very important, so far as our attempts to 
cure the case are concerned, and without an intelligent solution 
of them, our treatment will be experimental. Almost all our 
diagnostic means are physical ; the history and rational symptoms, 
although valuable, are much less so than personal inspection with 
various physical appliances. The utmost freedom of examination, 
therefore, should be insisted upon, before our patient can, of right, 
demand our opinion. This will neither be asked nor given until 
the case has assumed something of gravity and importance. I have 
known medical men to give an opinion on imperfect examinations, 
that they were afterwards under the necessity of reversing ; and, 
en passant, I think, as a general thing, more errors of diagnosis 
in female diseases are committed by the imperfect use of our now 
highly improved measures of exploration, than originate in any 
other way. 

The history will afford us in many cases, however, very valua- 
ble aid in arriving at correct conclusions. It is now pretty well 
determined that the average duration is about three years. In 
this time, it will spontaneously produce fatal effects, by great size 
and extreme distension, and the resulting damage. This is longer 
than pregnancy lasts, and a shorter time than is required for solid 
fibrous growths to reach the same results. The age at which they 



OVARIAN TUMORS. 417 

are most likely to occur is an average of twenty-six years, accord- 
ing to Mr. Brown, — although they may occur at any time during 
the active condition of the sexual functions, while the ovaria 
are subject to menstrual congestions and their effects. Quite a 
large number of- cases make their first appearance in early men- 
strual life. I knew one in which the beginning of the tumor 
must have been simultaneous with, if not antecedent to, the com- 
mencement of the function of menstruation. Fibrous growths of 
the uterus are not likely to begin so soon. Their increase after 
being first observed is comparatively rapid, more so in the young 
than those somewhat advanced in age. They are not usually at- 
tended with pain in their own proper substance ; this is not always 
true, for the congestion and hyper-excitement may be attended 
with pain and soreness. The functional disturbance, in their 
early stages, occurs in the pelvic viscera ; first, on account of 
pressure, such as tenesmus, dysuria, dragging, or weight in the 
pelvis ; and secondly, imperfect menstruation. Sometimes the 
menses are suppressed, scanty, and painful, but often no deviation 
is observed. The main thing in the history of the case, in this 
respect, is to remember that the symptoms point in the beginning 
to trouble in the pelvis. It is generally, or at least sometimes, 
stated that the tumor rises from one iliac region and continues to 
occupy one side for some time. This, I think, is the exception 
to the rule, that they are at first central ; and, by Dr. Frederick 
Bird, this is considered an evidence of adhesion. They probably, 
when large enough to overcome the support of their peritoneal 
envelope, fall into the cul-de-sac of Douglas, behind the uterus ; 
and then, as they grow, come up in front of the promontory of 
the sacrum, until they are large enough to be felt above the 
pubis, having their point of support in the hollow of the sacrum, 
instead of one of the iliac fossae. The patient will usually speak 
of it as a lump, instead of saying that she is swollen, as in preg- 
nancy. The abdomen does not enlarge generally, according to 
her statements, but by a tumor rising in it. She has watched it 
coming up out of the pelvis, and not starting from above or from 
one side, and encroaching upon the abdomen from either of those 
directions. The knowledge derived by physical examination, as 
already stated, is the most valuable ; and while the modes of pro- 
cedure are the same, and applicable to all stages of growth and 

27 



418 OVARIAN TUMORS. 

enlargements of the tumor, we will be able better to describe and 
understand them, as made use of for one that has arisen from the 
pelvis and pretty thoroughly filled the abdominal cavity, — a tumor 
that has become obvious, and from which our patient is solicitous 
of being relieved. The means aiforded us for physical examina- 
tion are — 1st, palpation ; 2d, percussion ; 3d, auscultation ; 4th, 
vaginal and rectal digital examination ; 5th, examination with the 
sound or uterine probe. These may be used separately, or com- 
bined in any given case, some being more valuable in some cases, 
and others in different ones. Exploring needles, chemical tests, 
and the microscope, may also be used to great advantage. Pal- 
pation is of very little use while the tumor is still in the pelvis, 
and can only be of avail -in conjunction with the vaginal touch or 
the uterine probe ; as it rises in the abdomen, however, this pro- 
cess of examination comes into use independently. In this condi- 
tion, we can examine the consistence, size, shape and mobility of 
the growth, and form some opinion as to its adhesion to the walls 
of the abdomen, and its primary attachments. In conjunction 
with some other processes of examination, it is more useful at this 
stage and size. 

In the ordinary condition of the contents of the abdomen, the 
intestines lie in contact with the anterior and lateral walls, except 
in the right and left hypochondria, where the liver, over a consid- 
erable space, and the spleen, a smaller, displace them. In conse- 
quence of this state of things, the resonance caused by the gas in 
the alimentary tube extends all over the anterior and lateral walls, 
save the above exceptions. Dulness upon percussion, therefore, 
indicates the presence of a tumor. The mesenteric attachments 
between the posterior wall of the abdomen and intestinal tube 
prevent them from being separated to any considerable extent, 
hence tumors occupying much space are apt to displace and get 
anterior to the latter. If the tumor springs from the pelvis, this 
is particularly likely to be the case, as well from the above facts 
as the direction given to it by the axis of the superior strait ; thus 
it is with the gravid uterus, uterine fibrous growths, and ovarian 
enlargements. Growths from the pelvis perhaps more completely 
gain the anterior position than any other sort, unless it be such as 
are attached to the anterior wall originally. It may be observed, 
too, that it takes a larger growth to disengage itself from intesti- 



OVARIAN TUMORS. 419 

nal resonance when arising from the posterior wall than from any 
other situation in that cavity. 

By percussion we may make out the boundaries, positions, and 
to some extent, attachment and contents of an abdominal tumor. 
We should begin at the pubis, and follow a line upward to the 
ensiform cartilage ; by so doing we will ascertain the central per- 
pendicular extent. A good plan is to make four or five perpen- 
dicular explorations of this kind each side of the median line, 
extending the whole length of the abdominal cavity. After this 
has been done, we may proceed, by right angles, to these lines, to 
examine the abdomen crosswise, from its lower to its upper bound- 
ary. We will seldom miss any important growth by this mode 
of proceeding. If there is any doubt or obscurity, our pressure 
should be sufficient to bring out something of the flatness of sound 
from the spine, kidneys, &c. If we discover any point of suffi- 
ciently defined dulness to impress us with the idea of a tumor, 
we should, by percussing explorations, proceed from the point of 
greatest dulness to its circumference in every direction. In this 
way of examining, we will be able to trace it up the side to the 
hypochondriac regions, down into the pelvis, or define it so per- 
fectly as to decide what must be its place of origin. Percussion 
and palpation will often enable us to determine the contents of a 
tumor as to its solidity or fluidity. Placing the finger on one 
side of the tumor, while we percuss the other, if the contents are 
wholly fluid, a wave of liquid will be set in motion on the side 
struck, and traverse the space to the one of the opposite ; if solid, 
of course nothing of this kind will take place, and the impulse 
will be given to the whole substance of the growth. Should the 
contents be fluid, separated by a number of partitions, the wave 
or fluctuation will be less distinct than in the one where no such 
division exists ; but in fact the obscurity is so great, that we will 
be at a loss by this management to decide whether, the contents 
are solid or fluid. A slight variation of this combination of tact 
and percussion will often clear it up, however. When we wish to 
ascertain whether the fluid is contained in several cysts, we should 
place the pulp of the fingers of the left hand in the centre of the 
tumor, and then percuss with those of the right, first very near, 
then gradually increase the distance between them, until we find 
a point at which the fluctuation becomes less distinct ; this is the 



420 OVARIAN TUMORS. 

margin of the cyst over which our left fingers are placed. Still 
keeping them in position, we percuss around in every direction, 
until we have made out the boundary and size of the cyst under 
examination, when we may move the fixed fingers to its margin, 
and commence the same process around this point. Proceeding 
in this way from one point in the abdomen to another, in most in- 
stances we may trace the outline of all the cysts superficially 
situated, and thus enumerate them, and learn their relation and 
absolute size. If solid bodies of whatever structure are incorpo- 
rated in the mass and superficially situated, they may be detected, 
and their relative position, size, &c, determined with some accu- 
racy. After tapping, when the abdomen is lessened, its walls lax 
and soft, palpation and percussion, singly or combined, become 
more demonstrative than before this operation. It not unfre- 
quently is necessary, on account of the sensitiveness of the pa- 
tient, when the tumor is small and the abdominal muscles not much 
under control of the will or reflex excitation, to administer chlo- 
roform until unconsciousness is induced, and the influence should 
often be so profound as to abolish reflex sensibility. In cases 
where there is inflammatory tenderness, the chloroform will give 
us a freedom of examination which is indispensable to an accurate 
diagnosis, and that we could not without it by any possibility 
obtain. Palpation and percussion should both be practised ordi- 
narily with the patient in the recumbent position on the back, 
with knees drawn up, shoulders elevated, and the abdomen strip- 
ped quite bare of covering ; in many instances, however, varia- 
tion of posture is indispensable to definite results, — the standing, 
prone, &c. Very little need be said in this place about ausculta- 
tion, as it is only applicable to the diagnosis between it and preg- 
nancy, and will be dwelt upon when I come to speak of that more 
particularly. Vaginal and rectal digital examinations in ovarian 
disease are proper, afid should not be dispensed with. The pelvis 
should be carefully surveyed by this method. The attachments, 
consistence, and relations of the diseased mass to the various or- 
gans in this cavity should be carefully noted. The uterus, rec- 
tum, and bladder, so far as practicable, ought to be examined with 
reference to their healthy condition, position, and involvement. 
Combined with external palpation, we may examine the tumor 
more thoroughly than with either one alone. Two fingers intro- 



OVARIAN TUMORS. 421 

duced into the vagina and pressed firmly upward against it will 
perceive any impulse imparted to the tumor above. With the 
left hand, if we press downward toward the pelvis, we may feel 
the motion of the diseased accumulation downward, and if the sud- 
den impulse of percussion is applied above, we may feel an im- 
pression from its contents; if fluid, a wave or sense of fluctuation; 
if solid, the deadened impulse always given in such cases. When 
the tumor is small, and occupies the posterior peritoneal cul-de- 
sac, by introducing one finger in the rectum and the other into 
the vagina, the tumor may be included between them, and thus 
examined with more accuracy than with either alone. 

Dr. Simpson has taught us how to extend our examinations into 
the uterus, so that our information in this direction is very mate- 
rially increased, by the use of the probe, mounted upon a handle. 
Members of the profession who appreciate the labors of Dr. Simp- 
son, have, by consent, named the instrument, the improvements 
and uses of which he has so ably promulgated, " Simpson's sound." 
The most useful form, I think, of the sound is round and plain, 
without any notches or edges, with the button-end about two lines 
in diameter. Back of the head or button-end the wire should be 
about half the thickness of the end. From this the wire should 
gradually increase in size towards the handle, until it is near a 
quarter of an inch thick. The material of which it is made should 
be soft enough to be bent into any shape we choose, and yet sufii- 
ciently firm to retain the flexure thus given. 

The sound may be introduced into the uterus, and varied in its 
direction while we geatly urge it forward to the extremity of the 
uterine cavity. The only obstacle a sound of the dimensions I 
have mentioned will meet with in a uterus of ordinary size, will 
arise from want of correspondence with the direction of the cavity. 
The most simple and ready revelation of the sound or probe is the 
direction and length of the uterine cavity. From this knowledge 
much valuable deduction may be drawn. But it is employed for 
determining the relation of the uterus to pelvic tumors, according 
to the ingenious directions of Dr. Simpson, very handily and to 
excellent purpose. While the sound is in the cavity of the uterus, 
this organ may be fixed by holding the instrument firmly in one 
position, or be moved in any direction if not restrained by adhe- 
sion or accretional attachment to the diseased mass, or to some 



422 OVARIAN TUMORS. 

other organ. If the uterus be fixed, and the tumor moved by its 
side or from it, with the fingers introduced for the purpose, the 
motion will be felt affecting the uterus through the attachments. 
On the other hand, if we watch the motion of the tumor with the 
fingers while the uterus is moved, the attachment or'not will be 
determined, or the uterus may be moved in one direction and the 
tumor in another. In this way their attachments may be pretty 
certainly diagnosticated. The sound may be employed in the 
uterus with one hand, while palpation on the abdominal surface is 
effected with the other ; and if the uterus reaches above the pubis, 
the distance the probe is separated from the external hand, or its 
relation with the median line of the abdomen, or the main bulk of 
the growth, will enable us to determine some interesting problems. 
The motion received by the sound from the pressure of the hand 
without, or vice versa, is of important significance, as will be more 
apparent as we advance. When, however, from all these sources 
of inquiry we fail to get a sufficiently definite answer, there is still 
another physical means of diagnosis which we are justified in em- 
ploying, viz., exploration. If by means of an exploring needle 
or trocar we draw off a small quantity of fluid, it may be sub- 
jected to microscopic and chemical tests, that will often enable us 
to determine the nature of the disease. Dr. G. Hughes Bennett, 
in a paper on Ovarian Disease, in the "Edinburgh Medical and 
Surgical Journal," quoted by Mr. Brown, says, as the result of his 
microscopic " examinations of different specimens of ovarian fluid, 
that the most constant characteristic of such fluid is its containing 
in greater or less abundance cells gorged with granules ; and in 
addition, circumambient granules, having the same measurement 
as those encompassed by the cell-wall. At one time I considered 
the size of these granules (if they can properly be so called) was 
constant, but subsequent observations have convinced me of the 
incorrectness of this conclusion : the size of the gorged cells and 
granules varies greatly, even in the fluids from different cysts of 
the same ovary." There can be no question but that the nature 
of the fluid contained in these cysts is, in all its essential features, 
pretty constantly the same in the early stages of progress ; but it 
is equally true that as they grow large enough to be influenced by 
pressure or other external causes, their composition, microscopi- 
cally, must vary. The chemical nature of this fluid is more con- 



OVARIAN TUMORS. 423 

stant. It is alkaline in reaction and highly albuminous, always 
coagulating when boiled or submitted to the action of strong acids. 
Another sort of exploratory examination is the evacuation of a 
part or the whole of the fluid, provided fluid flows through the 
tube. If so much fluid is drawn off as to greatly relax the abdom- 
inal parietes, the contents of this cavity may be much more thor- 
oughly examined by palpation and percussion, and the nature of 
the growth ascertained quite definitely. We can then handle the 
abdominal contents so as to trace any tumor within it to its attach- 
ments, get its precise size and shape, consistence, &c. Or if there 
should be no morbid growth, it will become quite evident after a 
greater or less evacuation of the fluid by tapping. 

After having passed in review, as above, the items of general 
diagnosis of ovarian tumors, I propose to enter upon a differential 
view of the subject, for there are conditions of disease and health 
of the contents of the female pelvis and abdomen which they may 
be mistaken for. The following list is given by Mr. I. Baker 
Brown of conditions that may be mistaken for ovarian tumor : 
" 1st. Retroversion and retroflexion. 2d. Tumors of the uterus, 
— solid, fibrous, or fibro-cystic. 3d. Pregnancy. 4th. Pregnancy 
complicating ovarian dropsy. 5th. Cystic tumors of the abdomen. 
6th. Distended bladder. 7th. Accumulation of gas in the intes- 
tines. 8th. Accumulation of faeces in the intestines. 9th. En- 
largement of the liver, spleen, or kidneys, or tumors connected 
with the viscera. 10th. Recto-vaginal hernia and displacement 
of the ovary. 11th. Pelvic abscess. 12th. Retention of menstrual 
fluid from imperforate hymen or closure of the os uteri. 13th. 
Hydrometra." . 

In cases of retroversion or retroflexion, if minute examination 
with the finger per vaginam and rectum fail, and the symptoms 
are of a character to make a correct diagnosis important, the 
uterine probe will at once determine the distinction. In some in- 
stances we might be quite unable to distinguish a small ovarian 
tumor from an impregnated retro verted uterus. Our proper plan 
in such cases is to await the peremptory demand for the knowl- 
edge, and then take the risk of introducing the probe, remember- 
ing the position of the mouth of the womb in retroversion, that it 
is not only near the pubis, but directed upwards as well as for- 
wards, and that the os, in cases of misplacement by the tumor, is 



424 OVARIAN TUMORS. 

not directed upward, but nearly always downward, — certainly 
never, so far as my experience and reading goes, above the hori- 
zontal position. The probe will be equally available in examining 
the retroflected organ, and I think the probe should always be 
used where pregnancy is not strongly suspected. Should we feel 
much doubt of the existence of pregnancy in connection with 
retroversion, it would be better to lift the tumor out of the pelvis ; 
when, if it were retroversion, the uterus would be restored to its 
natural position, with the os near the centre of the pelvis. In en- 
deavoring to distinguish between ovarian and uterine tumors, we 
should bear in mind that the latter almost invariably change the 
length and size of the cavity of the uterus. Where the sound is 
used, it will pass further than if the uterus was not involved. The 
rationale of this increase of size of the uterus, so generally found 
to be present, is, I presume, connected with the fact that the de- 
velopment of a tumor in or from the walls of that organ induces 
general hypertrophy to some extent, as these growths are found to 
be a hypertrophy of some one of the uterine tissues. The tissues 
generally involved are the fibrous or mucous, as in hard or soft 
polypi from the internal, or hard from the external walls or intra- 
mural fibrous tumors. Uterine tumors are so intimately connected 
with the uterus that this organ cannot be moved without imparting 
more or less motion to the tumor, nor can the tumor, on the other 
hand, be moved without, in a similar way, affecting that organ. 
This is not the case with ovarian tumors. They are so loosely con- 
nected with the womb that considerable motion is allowable with- 
out the other partaking of it. In the sound we have the means 
,of moving or fixing the uterus, and with the finger may watch the 
effect of motion upon the one or the other, as the case may be. 
When a fibro-cystic tumor is developed upon the uterus containing 
fluid, the examination to ascertain whether there is an attachment 
with the uterus, and with a view to learn the length of the cavity, 
will give us clear notions of the matter. When we are satisfied 
that pregnancy cannot be the condition, we may explore or tap it 
as an additional means of accuracy. 

Hard or fluid tumors arising from a distant organ or part of the 
abdomen would have a different history from the ovarian tumor. 
If our patient is intelligent, her observation as to the place where 
first noticed should be relied upon as valuable knowledge respect- 



OVARIAN TUMORS. 425 

ing the probable point of origin. Ascites, when excessive, may 
sometimes be mistaken for ovarian tumor, but the latter is more 
frequently taken for the former. When the patient lies on her 
back, with the knees drawn up, so as much as possible to relax the 
muscles, and the abdomen is entirely exposed, in ascites the tumi- 
dity will be rotund, filling out in every direction, and will particu- 
larly bulge the depending portions. The flanks will both be full ; 
the abdominal protrusion commences at the edges of the ribs, and 
will be equally soft at every point ; fluctuation will be greatest at 
the most dependent parts, and resonance entirely absent ; fluctua- 
tion will scarcely be perceptible in the highest part of the ab- 
domen. These circumstances will remain the same under any 
change of position. If the patient stand up, the dulness is in the 
hypogastric and iliac regions. If she lie on her side, the dulness 
and fluctuation on the lower side ; resonance on the upper side. 
All this results from the water freely settling into the lowest 
points, let them be what they may. In ovarian tumor, alteration 
of position from erect to recumbent, or from supine to prone, 
makes no difference in the places where resonance and fluctuation 
are found. They are manifested always in the same places. When 
the patient lies on the back, the flanks are resonant, the umbilical 
region dull. Fluctuation is not observed in the flank in any posi- 
tion ; it is apt to be greatest under any posture in the middle of 
the abdomen. When the abdomen is exposed for inspection there 
is marked irregularity in its rotundity, and I think, ordinarily, 
the flanks, one or both, are flat. One side is apt to bulge more 
than the other. Probably there is more than one rather promi- 
nent region, — it may be several. There is more hardness and 
tension i not the flabby swaying under slight influences, so common 
in ascites. An important class of circumstances is the patholo- 
gical condition almost always, present in ascites. It seldom occurs 
in persons in the enjoyment of good health in every other respect. 
There is organic disease of the kidneys, liver, spleen, heart, lungs, 
or subacute peritonitis. Or there may be some cachexia from 
miasma, poison, or other bad influence of particular places of 
residence, occupation, habits, or time of life, &c. There is 
some notable and grave pathological accompaniment of abdominal 
dropsy which precedes the swelling ; whereas, the ill health in 
ovarian dropsy is the effect and not the cause. We generally find 



426 OVARIAN TUMORS. 

that women preserve a good condition of health in ovarian disease 
until far advanced, and disordered functions come almost always 
as the result of great pressure upon the suffering organ. A com- 
plication of ascites with ovarian dropsy obscures our diagnosis 
very much. If the ascites is great, and the ovarian disease not so 
considerable, the tumor will be felt floating about, as it were, in the 
abundant fluid, when the patient changes position. Excluding by 
our diagnostic examination every other disease, and leaving the 
question between them alone, we are justified in exploration and 
even tapping. By the former, we come in possession of a specimen 
fluid, which, when submitted to chemical and microscopical inves- 
tigation, is almost conclusive. By the latter, we partially empty 
the abdominal cavity and relax the walls, so that we can examine 
its contents with great freedom. If the fluid is ovarian, it will be 
highly albuminous, and possess the microscopical qualities I have 
before mentioned. If it be ascitic, the properties are those of 
serum found exuded anywhere from pressure or inflammation. 
There will be very little, if any, albumen, no epithelial cells, and 
the corpuscles described by Dr. Bennett. 

It will occur very seldom that the question between pregnancy 
and ovarian disease will become so urgent that it may not safely 
be left to time. I can conceive no time or circumstances under 
which great doubt as to which of these two conditions were pres- 
ent but in the early stages of either, while in the pelvic cavity ; 
and unless great pressure on the organs contained in it make delay 
hazardous, we should not interfere, but content ourselves to wait 
until the obvious evidences, as quickening and motions of the child, 
declare the existence of pregnancy, or until so much time has 
elapsed without any such signs as to throw great doubt upon the 
subject. At such times the tumor is high above the pelvis, and 
may be subjected to any searching examination we may choose. 
Auscultation then becomes valuable and perfectly reliable, when 
properly practised, in determining the presence of normal preg- 
nancy. 

Frequent examinations with the stethoscope or ear, in various 
positions, should be patiently and perseveringly practised before 
we should be satisfied to risk means of a hazardous nature that 
will enable us positively to decide the question. After having re- 
peatedly thus explored the abdomen without any sign of a live 



OVARIAN TUMORS. 427 

foetus, we may use the probe to examine the whereabouts and size 
of the uterus. No mistake will survive the test of this instrument. 
If I were not to explain myself a little more upon this point, I 
might incur the charge of rashness for recommending the sound 
where any doubts exist. It would be rash to use the sound until 
all the differential signs of pregnancy had failed, and even then, 
unless the urgent demand caused by the influence upon the health 
forbids us to wait longer for a decision. It is .only in extreme 
cases, where the symptoms and signs derived from the breasts, 
menstruation, nausea, pigmentary deposits, and auscultation, had 
all failed, and yet I was obliged to act at once for the safety of 
the patient, that I should consent to use the sound. Then I would 
use it as the more innocent of the demonstrative tests, and as a 
dernier ressort. It is certainly more innocent than the exploring 
needle or evacuating trocar, and equally demonstrative. The 
worst effect its careful use could have would be to produce abor- 
tion or premature birth, either of which would be more likely to 
remove the urgency of the symptoms than do harm. I have re- 
cently seen an instance of obscurity of diagnosis, from the exist- 
ence of a pregnancy of eight and a half months' duration, decided 
by the probe, which caused the discharge of a mummified foetus of 
less than four months' growth, and, as a matter of course, almost, 
cured the patient. 

Pregnancy complicated with ovarian dropsy, may be very per- 
plexing to diagnosticate. At a sufficiently advanced stage of 
pregnancy, auscultation will reveal the fact, and it cannot be a 
matter of great importance to decide the nature of the tumor un- 
til the termination of the process of gestation, as a general thing, 
and if it should, we may proceed in its examination according to 
the plan heretofore indicated. This complication may continue 
up to the time of labor, and embarrass that process. Such em- 
barrassment will not arise, if the tumor is large enough to rise 
out of the pelvis, but if it is still within that cavity, and gets be- 
low the child's head, it may arrest its progress. There are very 
few collections or growths that can be, in such conditions, mis- 
taken for this. In pelvic abscess, there will be inflammatory ten- 
derness and heat. The most likely of all others, is a prolapsed 
bladder. Our diagnosis, however, will be easily effected by using 
the catheter, when, if it is the bladder, emptying causes its col- 



428 OVARIAN TUMORS. 

lapse and the entire disappearance of the tumor. But if, after 
the complete evacuation of the bladder, there is yet a tumor con- 
taining fluid, exploration should be resorted to. This will clear 
up the diagnosis, provided the exploring trocar is large enough 
to evacuate a part or the whole of its contents. There are other 
fluid tumors, arising from the broad ligaments near the ovary, 
probably dependent upon a great increase of one or more of those 
transparent cells of serum, so generally seen by looking through 
this peritoneal duplicative, towards the light. These may be mis- 
taken for actual ovarian cysts, and these are doubtless the cases 
of ovarian disease that are permanently cured by a single tap- 
ping. I think no means of diagnosis now known w T ould enable 
us to decide, with any certainty, between the two. Exploration 
and chemical and microscopic examination of the fluid would throw 
some light upon, but not necessarily clear up the case. Cystic 
tumors of the abdomen, arising from other points, and hydatids 
of the peritoneal cavity, can be distinguished with certainty in no 
way except by exploration and examination of the contents. The 
history will, if carefully and intelligently detailed, show some- 
thing, perhaps, that we may seize upon to aid us. The case 
should commence, if ovarian, in a tumor arising from the pelvis 
gradually ascending into the abdomen. If abdominal, it is first 
noticed in that cavity, and may descend until it occupies all the 
abdomen, and then the pelvis also. If hydatid, the increase is. 
mere tumidity, not a well-defined tumor, and it commences in the 
abdomen. 

The distended bladder, accumulation of gas in the intestines, 
or of faeces, ought not, in the present state of our science, to em- 
barrass us any longer than the catheter or a cathartic could be 
brought to bear upon the case. As soon as the bladder is emptied 
it will collapse. The gas in the bowels causes tympanitis of the 
abdomen, and thus ought to be detected. The accumulation of 
faeces can be removed, when the tumor will be gone. Hysterical 
distension of the abdomen, said to simulate pregnancy, ovarian, 
uterine, and other tumors, entirely disappears under the influence 
of chloroform, as shown by Prof. Simpson, on many occasions. 

Visceral enlargement, as liver, spleen, kidneys, and tumors 
growing from them, are not unfrequently mistaken for these tu- 
mors. I have a patient now laboring under enlargement of the 



OVARIAN TUMORS. 429 

spleen, who has been told more than once, that she had ovarian 
disease. Unless the enlargement of the liver or spleen is exces- 
sive, I cannot see how a mistake can be possible. The history 
as to where the tumor was first observed should be carefully 
traced. If either of these, it has descended. I have not seen a 
liver or spleen occupying the cavity of the abdomen so completely, 
but that its well-defined edge could be felt for a considerable dis- 
tance, and this edge is always below, while the upper boundary is 
less defined or traceable beneath the ribs. I have, on several oc- 
casions, seen the spleen enlarged and dislocated, occupying the 
left iliac region, and reaching up towards the hypochondriac, but 
there are always sharp edges somewhere. This is not the case in 
ovarian dropsy ; it is found, somewhat even, and elastic to the 
touch. 

Mr. Brown mentions recto-vaginal hernia and dislocation of 
the ovary into the cul-de-sac of Douglas. The diagnosis would 
be difficult, and unimportant, unless in exceptional cases. The 
great importance of a correct diagnosis is based upon the urgent 
symptoms and fatal tendency of the disease. If the tumor is small, 
and situated in the cul-de-sac, we can not only afford to wait for 
further developments, but it is our duty to do so. 

Retention of menstrual fluid, from imperforate hymen (or other 
obstruction to its outlet), — hydrometra, — as soon as we have by 
physical examination, history, and the rational symptoms, decided 
that the patient is not pregnant, the finger and sound will clear 
up all doubts in a short time. Obstructions will be ascertained or 
overcome by them, and our misgiving dispelled. 

Supposing our diagnosis complete, as to its being an ovarian 
tumor, we have yet to learn, for the more intelligent treatment, 
several other things ; among these are, — What are the contents 
and construction of it ? Is it monocystic or polycystic ? Are its 
contents partly solid, or wholly fluid ? Although, probably, not 
always possible to decide these questions without exploratory 
operations, we have some means of clearing them up. A diligent 
and careful examination by percussion and inspection will enable 
us to judge correctly, in most cases, whether the tumor is mono- 
cystic or polycystic, or otherwise. If monocystic, the tumor is 
regular in its rotundity and outline ; if polycystic, there is some 
irregularity of elevation, made out best by sliding the hand oyer' 



430 OVARIAN TUMORS. 

the surface. Fluctuation, caused by percussion, is the same in 
all directions and from all points of it in monocystic. In poly- 
cystic, it is very obscure, except over partial measurements. The 
fingers placed near each other over the same cyst feel the fluctua- 
tion very sensibly ; but when one is removed so as to pass over 
the partition between it and the next cyst, the fluctuation becomes 
more obscure. By examining all parts with both hands, separat- 
ing and approximating each other, we may make out the dimen- 
sions and situation of the cyst, which lies in contact with the ab- 
dominal walls. The fluctuation, or its absence, will determine 
whether a given part of the tumor is solid or fluid. The hard 
parts of an ovarian tumor, are, almost invariably, at the bottom 
of the tumor, and may be reached by the finger per vaginam. 
While our fingers are in contact with the base of the tumor in the 
pelvis, if it is wholly fluid, we may feel fluctuation, if the top of 
the tumor is struck with the other hand. If a solid part inter- 
venes between our two hands, fluctuation would not be experienced. 
A very important and difficult point in our diagnosis, is the 
presence or absence of adhesions to the viscera or walls of the ab- 
domen. The nature of our practice will depend very much upon 
the determination of this question. Adhesions are very much 
more frequent in front than behind the tumor ; to the walls of the 
abdomen than to the viscera. There is no way, so far as I am 
informed, to decide whether there exist adhesions to the mova- 
ble viscera, and unless when the tumor is small and movable, 
whether it is adherent behind or not. If there is none in front, 
there is not likely to be any behind. If there has been no peri- 
toneal inflammation nor signs of other inflammation in the abdo- 
men, we should be encouraged to hope that there is no adhesion, 
for there can be little doubt that adhesions are more frequently 
the result of organized inflammatory effusions between the two 
surfaces of the peritoneum, than all other causes. This is the ex- 
planation of adhesions, following punctures with the trocar or 
exploring needle. If the patient has always enjoyed good health, 
and not suffered from pains in the abdomen, there has probably 
been no irtflammation, and therefore no adhesion. It should not 
be inferred, however, that there is certainly no adhesion because 
there has not been any inflammatory symptom ; for either these 
symptoms may have been so obscure as to have escaped observa- 



OVARIAN TUMORS. 431 

tion, or the adhesion may have resulted from some other cause. 
Certain it is, adhesions do exist in many instances without any- 
thing in the history of the case leading us to suspect them. We 
should inquire whether any operation, pressure or other curative 
measures of a local nature, have been used, as almost all of them 
endanger adhesions to the front wall of the abdomen. 

If there is not too great tension we may gather the walls of the 
abdomen up, and move them over the tumor to a sufficient extent 
to establish their freedom from adhesions. In fact, there is not 
much adhesion where we can thus raise the muscles in folds. 
Another way is to place one hand on each side of the abdomen, 
with the palms applied flatly to its surface, and, pressing with 
some firmness against the tumor, we may attempt to slide the walls 
over the growth. As adhesions are not apt to be universal over 
the anterior part, a difference in the mobility of certain parts 
would lead us to point out the probable localities and extent of 
these complications. The hands should be moved from place to 
place until all the surface has been thus examined. This, when 
properly and carefully done, is a valuable means of examination. 
When the patient is lying on her back, with the walls as much re- 
laxed as possible, if she make several deep inspirations we may 
observe the muscles moving over the growth, or see that the whole 
mass is carried down together. When in the same position, if 
the patient will make an effort by the abdominal muscles alone to 
elevate the chest, or throw her head forward, if there is no adhe- 
sion under the rectus muscles, these organs will show their bellies 
distinctly by swelling up in their middle portion. If there is ad- 
hesion on one side and not on the other, the muscle that is free 
will bulge, while the other remains flat and undefined in any such 
way. If both are adherent, the whole will remain smooth under 
the efforts. If the adhesion is at the lower part and not at the 
upper, the bulging will take place above, and not at all below. 

Treatment. — It is not necessary to interfere, in any manner, 
with some cases of ovarian dropsy. Indeed, it is right to let all 
cases alone that do not threaten the life of the patient. There are 
many instances which advance slowly, or remain stationary for a 
great many years, and prove but an inconvenience. We would 
not be justified in active interference in these cases ; much less 
should we do anything directly for cases in which independent 



432 OVARIAN TUMORS. 

complications of a fatal character exist, e. g., phthisis or cancer. 
When, however, the disease is making obvious progress, and par- 
ticularly when the advance is sufficiently rapid to leave but little 
doubt of its proving fatal within the average time of their dura- 
tion, we are bound to make every effort within our power to save 
or prolong, as much as possible, the life of our patient. 

When treatment becomes necessary, and we cast about for rem- 
edies, we will find that there are two kinds of treatment, strongly 
distinguished from each other, applicable to certain classes of cases 
respectively. General hygienic treatment is applicable to all, and 
this will consist, for the most part, in an abstinence from every- 
thing that stimulates the ovaria, — heated rooms, high living, las- 
civious practices, marriage, or if married, sexual intercourse and 
pregnancy ; and the use of appropriate outdoor exercise, proper 
diet, and, indeed, everything calculated to promote sound health, 
and an avoidance of all debilitating influences. 

The two kinds of treatment alluded to are the palliative and the 
curative. The one intended to relieve, as far as possible, the suffer- 
ings of the patient under the disease, or to retard the rapidity of 
its progress ; the other to remove or destroy the tumor, and thus 
do away with the cause of the evil entirely. When practicable, 
I think this last treatment is always desirable ; when not practi- 
cable, as, unfortunately, is too frequently the case, our only re- 
source is the former. 

So far as my influence goes to enforce the rule, I should em- 
phatically insist upon determining in the beginning, before we 
make a move toward operative treatment, the kind of means 
adapted to the case under consideration ; institute that treatment, 
and persevere with it to the end, or until some circumstance occurs 
to convince us of our mistake in this respect. We should not begin 
by trying what is usually regarded as the least hazardous, and be 
ready to use the more dangerous, but yet more effective, because 
the former had failed. There is no treatment worth relying upon 
but must produce its effects ; and in nine cases out of ten, if it 
does not cure, it will cause disagreeable and e^en dangerous com- 
plications, and so render the subsequent treatment less effective. 
No case in which tapping, injections, or efficient pressure has been 
used ineffectually, is ever left in as good a condition for extirpa- 
tion as before any such interference. Hence, I would not tap a 



OVARIAN TUMORS. 433 

tumor that ought to be extirpated, nor allow it to be injected or 
compressed. It may be said, and it is unquestionably true, that 
we may not always be able to determine the character and compli- 
cations of the tumor, so as to be certain which treatment is best 
adapted to it. In answer to which, I would say, we must do the 
very best we can in this respect ; and I think by thus forming and 
acting upon our judgment, more lives will be saved than by con- 
founding the remedies in the manner heretofore done, using them 
more with reference to their danger and efficiency than their adap- 
tation to the particular case. It would seem that practitioners are 
divisible into two classes as to their mode of treating ovarian 
tumor, viz., those who believe that radical treatment should almost 
always be avoided, and those who believe in operating in nearly 
every instance. 

Two prolific sources of embarrassment in the treatment of ova- 
rian diseases are, first, the knowledge on our part of their almost 
invariably fatal tendency; and, second, the inability of our patient 
to appreciate the appalling nature of her condition until such con- 
stitutional effects have been produced as would render any efficient 
treatment powerless to save, — at least this has been the case with 
my patients to some extent; and hence we should make a clear and 
decided statement to them so soon as we become able by our in- 
vestigations to do so. When doubt exists as to the propriety of 
instituting radical treatment, we should continue to pursue the 
palliative until that doubt is dispelled. There are three sorts of 
cases to which the palliative is indisputably adapted. They are, 
first, those in which it is not desirable to use radical means in con- 
sequence of the absence and probable great distance of urgent 
symptoms, while there is a steady advance. It may as well be re- 
marked here that no palliative measure, such as tapping, great 
pressure, or other means that will render radical treatment more 
hazardous, should be employed, where we are likely in the future 
to desire to resort to operative procedure. The second class of 
cases is that in which the symptoms are urgent, but in which it is 
not desirable to use radical means, in consequence of the slight 
chances of success. The third set are such as, in their nature and 
condition, would call for curative means, but the patient will not 
consent to their employment from fear of the danger or pain they 
inflict. The first set of cases is not very frequently met with com- 

28 



434 OVARIAN TUMORS. 

pared to either of the others ; yet we do occasionally meet with 
these slowly marching cases, in which we have an opportunity to 
try the effect of medicines ; and it is precisely in this kind of cases 
that we appear to derive most benefit from medicines internally 
administered. We are prone to believe that the tardy develop- 
ment is dependent upon the virtue of some favorite remedy used, 
and deceive ourselves as to its efficiency, when really all depends 
on the natural slowness of the tumor. The alteratives, as mer- 
cury, iodine, sarsaparilla, chlorine, &c, have all had their advo- 
cates. It was at one time, and even now is the practice of some 
men of ability to give mercury to very slight ptyalism, with the 
hope of bringing about absorption. Iodine, administered fre- 
quently, so as to induce its specific influence upon the organism, 
has been, and is still, by some, highly lauded as capable of curing 
ovarian dro]3sy. A chronic administration of either of these rem- 
edies is sure to affect unfavorably the general health; and as it 
is extremely doubtful whether there is any efficacy in them, we 
should not be too profuse in their use. Effusion into the perito- 
neal sac, or subacute inflammatory complications, are often very 
much benefited by a moderately protracted course of these reme- 
dies. For the same purpose, local depletion, counter-irritants, 
such as iodine ointment, strong enough to induce irritation of the 
skin, are often useful ; so are diaphoretics, diuretics, and cathar- 
tics. But, probably, the best course to pursue in these cases is to 
keep up the general health by appropriate exercise, diet, and 
tonics when necessary, and to keep the abdomen constantly but 
gently compressed by a flannel roller, which should be applied all 
over the abdomen, but applied with more stringency over the 
tumor, and, to add to its efficiency, a compress of sufficient thick- 
ness may also be employed. I must be permitted again to say, 
with reference to all these cases, that until the necessity for active 
interference, in consequence of the urgent effects of the growing 
tumor, is fairly presented, we should carefully avoid all very strong 
pressure or operative procedure. In the second class of cases we 
need not feel so restricted in our efforts at palliation. It is best, 
however, to bear in mind that too great activity of medication will 
often do more harm than good. Our object should be to promote 
such functions as are obstructed or restricted ; the kidneys, for 
instance, will need especial attention, as will the intestinal canal. 



OVARIAN TUMORS. 435 

The acids have always seemed to me to be particularly applicable 
to these cases. The nitric, nitro-muriatic, sulphuric, phosphoric, 
acetic, are all good, and may be alternated often, with the hope of 
relieving the distressing indigestion attendant upon great disten- 
sion and imperfect performance of the renal functions. They also 
very much moderate the distressing exudations from the skin, 
which are often present. The chlorinated tincture of iron is an 
excellent tonic in such cases. These remedies may all very prop- 
erly be administered in some of the bitter infusions, quassia, 
chamomile, wild-cherry bark, &c. The best time to give them is 
immediately after eating. Stimulants ought not to be too freely 
used, as they encourage the establishment of complications. 
Brandy I think the best of the stimulants, and it should be given 
more for the purpose of inducing sleep than anything else ; and 
this it will often do when taken in a sufficient dose on an empty 
stomach at bedtime. When great restlessness and want of sleep 
are wearing out the patient, we must, as in all similar circum- 
stances in other diseases, resort to the assortment of anodynes, 
beginning with the less disturbing, being sure to be under the ne- 
cessity of ending with opium. Chloroform, internally adminis- 
tered, is, I am confident, not sufficiently relied upon. Teaspoonful 
doses, given in milk, will seldom fail to induce a fine anodyne effect. 
There is greater necessity, perhaps, for a gradual increase of the 
dose in using it than opium, or most other efficient anodynes. 
Hyoscyamus, belladonna, cicuta, should all be tried before opium. 
We must be on the alert for complications, and ready for their 
appropriate treatment. The distressing constipation, which often 
annoys the patient and physician, will demand a great share of 
our attention. Injections of water and various substances will, of 
course, suggest themselves. It has occurred to me to be able to 
induce free movements of the bowels by having a pint of warm 
lard thrown high up in the bowels when they are very obstinate ; 
the longer the lard is retained the better. This, administered once 
a day, will act excellently well sometimes. An ounce of fresh 
beef's gall, with three or four ounces of water, often does as well. 
But the time comes, sooner or later, with the steadily increasing 
pressure of the tumor, when to lessen its size is indispensable to 
the further extension of life. Tapping suggests itself as the only 
palliative means in this state of things. This operation is more 



436 OVARIAN TUMORS. 

beneficial in unilocular tumors than in any other sort, but is appli- 
cable as a palliative measure in any tumor containing fluid, when 
demanded by the supervention of urgent symptoms indicating the 
necessity of immediate relief. Under the desperate circumstances 
mentioned, there can be no question about the propriety of tap- 
ping the patient ; yet this apparently trifling operation is not de- 
void of inconveniences and dangers that should be weighed delib- 
erately ; and if they do not deter us from resorting to it, will at 
least make us particular not to use it as anything but an indis- 
pensable remedy. One serious inconvenience connected with tap- 
ping is the readiness with which the fluid accumulates in the sac ; 
indeed, the oftener the patient is tapped, the more rapidly will ac- 
cumulation take place. If, therefore, we commence using it too 
early, we are likely to shorten the life of the patient, if in no other 
way than by the increasing emaciation dependent upon the im- 
mense drain of fluid from the system. 

The dangers of tapping are both immediate and remote. The 
immediate are such as are connected with and occur immediately 
upon the performance of the operation. Dr. Simpson sums up five 
that are more frequent, and against which we should be upon our 
guard. First, the chance of wounding the urinary bladder. This 
may be avoided by evacuating the organ, unless it is tied to the 
abdominal wall by adhesions. Second, the puncture of the uterus 
w T hen it is drawn up with the tumor. By introducing the sound 
into its cavity we may learn its whereabouts, and thus be enabled 
to avoid it. Third, the front part of the tumor may be traversed 
by the Fallopian tube, and this last be wounded by the trocar, — 
an accident which should, of course, be avoided when we can, but 
which I cannot think of much importance, nor do I know how it 
can certainly be avoided. Fourth, the internal venous circulation, 
on account of the pressure, is obstructed sometimes, and the blood 
is directed to the veins in the walls of the abdomen, so that these 
veins may be wounded ; but generally they are large, and may be 
seen, and thus avoided. Fifth, the epigastric artery is sometimes 
wounded. We should carefully feel for the pulsation of arteries 
in the thin walls before the trocar is plunged into the tumor. As 
may be seen, these dangers may, for the most part, be provided 
against ; but the second class of dangers, namely, the remote, — 
those that follow the operation some time after its performance, 



OVARIAN TUMORS. 437 

and are not dependent on the manner or place of the puncture, — 
are unavoidable, and cannot be foreseen. 

The dangers and benefits of tapping cannot, and ought not, to 
be estimated by comparison with other operations. Each opera- 
tion, of whatever kind, has its place, and is followed by its good 
or bad effects, for the reason, among others, that it is appropriate, 
or inappropriate. Generally, no two operations are applicable to 
any one condition of things ; and we should not allow the question 
of danger to decide between them, unless in very rare and excep- 
tional cases. The statistics, as far as I have been able to collect 
them, may be well summed up, as Dr. West has done, and I shall 
rely upon his figures : " The chief, indeed, almost the only numer- 
ical data of which we are possessed, bearing on this subject, are 
derived from a table of 20 cases, compiled by Mr. Southam, of 45 
cases collected by the late Mr. Lee, and of 64, the results of which 
are given by Professor Kiwisch. Of these 130 cases, 22 termi- 
nated fatally within a few hours or days after tapping, and 25 
more in the following six months; or in other words, 34.7 per cent, 
of the cases ended in the patient's death in the course of half a 
year after the performance of tapping. In 114, of the 130, death 
is stated to have taken place : 22 within less than ten days, 25 
within six months, 22 within one year, 21 within two years, 11 
within three years, 13 after a period exceeding three, and in some 
amounting to several years. 

" In 109 of these cases, we are further informed how often the 
patients had been tapped. It appears that 46 died after the first 
tapping, 10 after the second, 25 after from three to six tappings, 
15 after seven to twelve, 13 after more than twelve." It would 
appear that the first tapping is very much more dangerous than 
subsequent ones. Dr. West says further : " Unfavorable, however, 
as are the conclusions to which we are irresistibly led by such facts 
as those which have just been mentioned with reference to the ulti- 
mate issue of tapping, it is yet very questionable whether they 
represent the whole of the truth concerning this matter." Dr. 
Atlee, of Philadelphia, thinks tapping not a very dangerous oper- 
ation. Mr. Brown thinks its dangers greatly overrated. 

There can be but little doubt that much of the mortality of tap- 
ping is due to the fact of the desperate character of the cases in 
which it is used ; and the reason why so many die in so short a 



438 OVARIAN TUMORS. 

time after the first operation is, that in many instances the patient 
is almost moribund before it is resorted to. When not attended 
with the immediate dangers above enumerated, tapping is either 
followed by great relief from suffering or by the remote or sequen- 
tial dangers. They are, for the most part, prostration or inflam- 
mation. The prostration is sometimes so great, that no manage- 
ment can prevent the patient from dying in a very short time. 
Such great prostration is, however, exceedingly rare ; it is more 
common to have it in a more moderate degree. The patient will 
feel faint for an hour or two, and then gradually rally, or she may 
continue to be pale and languid for several days. For such 
slight cases, the horizontal position, rest, and good, digestible, 
somewhat stimulating food, is all that will be needed. When the 
prostration is great, and danger of fatal sinking present, the case 
must be treated energetically. The means calculated to bring 
about reaction must have reference to the causes of the prostra- 
tion. The evacuation from the general vascular system is not a 
cause, because the fluid in the tumor is extravascular ; but it is a 
sudden change in the distribution of the blood. The evacuation 
of the abdominal cavity of so large a bulk of its contents, and the 
inability of the abdominal muscles to contract sufficiently to keep 
up the pressure to which the viscera have been habituated, are 
the causes of the irregular distribution of the blood. The want 
of pressure upon the abdominal viscera, allows a large accumula- 
tion of blood in the veins, and it is there retained. In propor- 
tion to the amount thus collected in the abdomen, will the blood 
be withdrawn from other parts and organs. The brain will par- 
take of this temporary ansemia, and consequently be incapable of 
discharging its functions with its wonted efficiency. This is the 
condition, — not a want, but an irregular distribution of blood. Our 
first object should be to, as nearly as possible, re-establish the 
previous condition of the abdomen. This can be, to some extent, 
accomplished by pressure, with compresses and rollers. The com- 
presses should be as large as the space covered by the muscles of 
the abdomen, and thick enough to fill up much above the level of 
the ribs and iliac bones on the side. The roller should be applied 
from the pubis to the ensiform cartilage, with as much power as 
the patient can bear without great discomfort. Then the head 
should be persistently kept below the level of the body. This 



OVARIAN TUMORS. 439 

simple treatment, instituted early, will do more than all other 
means without it. * We can very properly, however, give stimu- 
lants, in addition, when necessary. When this danger is passed, 
inflammation of the sac or peritoneal cavity is next to be appre- 
hended. The sac undergoes every degree of inflammation, from 
the slow, subacute, unobserved degree, which vitiates the fluid ef- 
fused into it, either by causing decomposition in it, or by the pro- 
duction of pus, or effusion of blood inside, or fibrine on the external 
surface — in this last case causing adhesion, — or such degeneration 
of the walls of the sac as to cause an obliteration of the cavity, a 
cessation of its secreting powers, or a perforation, and consequent 
peritoneal communication ; or, what is perhaps more common, an 
acute degree, announced by severe pain, referred to the point most 
intensely affected, or to the whole abdominal region, thus showing 
the probable involvement of the peritoneum. Indeed, I think it 
very probable that the sharp pain ordinarily present in these cases, 
indicates peritoneal inflammation, and that there is but little pain 
in the case of inflammation of the fibrous and internal coats of 
the sac. Fever, of a somewhat high grade, is apt to attend upon 
the degree of inflammation last mentioned, accompanied by head- 
ache, weariness, aching in the back, limbs, &c. But in the in- 
flammation of the inner coats, in which pus or fibrinous products 
are effused in the fluid of the tumor, there is generally but slight 
fever, perhaps none, at first ; but the vital powers are more or 
less depressed, copious perspirations at night, possibly delirium, 
and in bad cases, all the symptoms of pyaemia, hectic, exhaustion, 
and death. Now all morbid conditions resulting from tapping 
should be met promptly by the remedies appropriate to them when 
they occur under other circumstances, — antiphlogistic regimen, 
depletion, fomentations, cathartics, anodynes, alteratives, &c. In 
pysemia, tonics, stimulants, good diet, and time will be our resort. 
The operation of tapping is simple, and easily performed gener- 
ally. To avoid the depression which follows the evacuation of 
so large a quantity of fluid as is contained in the abdomen some- 
times, we should have our patient on the side, very near the edge 
of the bed, with her head and shoulders low. Two large and long 
hand-towels should be passed around her body, with the edges 
close together upon a level with the point where we wish to intro- 
duce the trocar, and these ends given to an assistant, w T ho stands- 



440 OVARIAN TUMORS. 

behind the patient. The assistant having in charge these hand- 
towels should be directed to draw upon them so as to keep up a 
state of tension as the fluid is being evacuated. To avoid the 
dangers enumerated as immediate, we should assure ourselves that 
the bladder is empty, and if we mistrust that it is not in its proper 
place, we should introduce a sound, so as to assure ourselves of 
the whereabouts of the fundus. If we have not already done so, 
we must sound the uterus, also, and thus be sure of its harmless 
position. After these precautions, the best rule, perhaps, is that 
given by Dr. Simpson, and that is, to feel for the most fluctuat- 
ing point, the place where the walls are thinnest, — look for veins 
and feel for the pulsation of arteries. The thinnest part, where 
fluctuation is most evident, is usually the right place to make the 
puncture ; but there is not always any such point, there being but 
little difference in this respect over the whole of the front surface 
of the tumor. In such case we may be governed by the ordinary 
rules for the place for tapping. The linea alba, between the sym- 
physis and umbilicus, is the most eligible in the greatest number 
of cases. If any objection to this arises, a point midway between 
the umbilicus and the anterior superior spine of the ilium is, as a 
general thing, safe and effectual as any. Some surgeons recom- 
mend other places as free from the objections that are sometimes 
urged against these points. They say that tapping through the 
vagina is quite safe from the immediate, and not so likely to be 
followed by some of the sequential disasters. The rectum is 
thought to be still better by some. The vagina is quite a com- 
mendable place, if we are careful to ascertain well the position of 
the bladder and uterus, and avoid them. Our instrument (the 
trocar) should be large, four or five lines in diameter ; the point 
should be sharp, and a little longer than they are usually made. 
The canula if not large will not freely discharge the fibrinous 
concretions or thick treacle-like fluid, and if the point is not long 
and sharp, we inflict considerable unnecessary suffering in the in- 
troduction of the instrument. We may plunge the instrument in 
towards the central axis of the tumor, until sent home to the rim 
of the canula. If, however, our instrument is not pretty sharp, 
it will be very much better to make an opening with a very sharp, 
thin bistoury, which will cause less suffering, and answer every pur- 
pose as well. 



OVARIAN TUMORS. 441 

The third sort of cases to which palliative treatment is appli- 
cable, those in which our patient will not submit to radical means, 
must be managed in almost every particular as I have described 
the treatment for the other two kinds. Remembering the rules 
and rationale, it will not be difficult to adapt our means to the end 
in view. 

The curative treatment of ovarian disease is believed by many, 
almost all authorities, to be practicable only by instrumental 
means. There are some very respectable writers, however, who 
believe that there are cases in which we may hope for success from 
medicinal and mechanical treatment without the use of surgical 
instruments, and they think that there is enough virtue in such 
means to warrant a trial in very many instances. 

The immediate objects to be accomplished are, first, to arrest 
the growth of the tumor, bring it to a stand-still, and thus avoid 
the disastrous results which attend the attainment of very large 
size, with its consequent pressure, ruptures, &c. Second, when 
this is not practiceable, to obliterate the sac or sacs. The sac is 
sometimes reduced by contraction to a mere knot of compressed 
tissues, which are more and more atrophied and wasted, until very 
slight traces of their existence are left ; or, by inflammation and 
contraction, the tumor is converted into a fibrinous mass, enveloped 
in a fibrinous sac, which remains the same throughout life with 
very little alteration; or suppuration may accompany inflamma- 
tion, the whole tumor be softened down into pus, and discharged 
by ulcerating through the vagina, rectum, abdominal walls, or 
bladder, and all traces of it disappear. Or again, the walls may 
collapse without shrinking much, and adhere by adhesive inflam- 
mation, and in this way its effusive surface be destroyed. 

When neither of the above two immediate objects is practicable, 
or it may not be desirable or advisable to attempt them, we may, 
thirdly, remove the whole or a part of the tumor from the ab- 
domen, and thus either get rid of the whole of the offending 
growth, or, after a part is removed, hope to effect, by one of the 
processes of obliteration above alluded to, the destruction of the 
balance. The means used for the arrest sometimes cause an ob- 
literation of the sac, and do more than merely stop its growth, so 
that it will not be the best plan to formally treat of those means 
by which we attain the first object desired. I shall consequently 



442 OVARIAN TUMORS. 

feel at liberty to introduce and speak of such as sometimes arrest 
and sometimes cause a disappearance of the tumor. 

Three general ideas seem to govern individuals who rely largely 
upon the use of internal remedies for the cure of ovarian dropsy, 
viz., that the disease is inflammatory in its origin and continuance, 
and that antiphlogistic and alterative remedies, by arresting this 
morbid process, will stop its growth, and that the conservative 
powers of the system, aided by sorbefacients and secernents, will 
remove it ; that the tumor is developed in consequence of the pres- 
ence of some one of the cachexia, — scrofula, for instance, as Dr. 
Bird distinctly avers. Physicians who entertain these notions of 
its origin hope to make a cure by changing the general action of 
the system by all the means usually recommended for the cor- 
rection of scrofulous tendencies to disease, by tonics, good diet, 
properly regulated exercise, clothing, bathing, and specific medi- 
cation; that its origin is entirely independent of either inflamma- 
tion or scrofula, — an hypertrophy, in the strict sense of the term, 
of certain normal conditions, — a nutritional development of tissues 
similar to the production of nutrition elsewhere. Those who en- 
tertain this doctrine believe, also, in the atrophicating qualities of 
certain medicines and mechanical appliances, and hope, by the 
well-directed employment of them, to at least arrest their growth, 
if not cause their removal by absorption. A number of cases are 
on record that encourage the hope of doing something by medi- 
cines internally administered ; and while I am free to state that I 
have really hardly any faith in them as curative means, the recol- 
lection of the discouraging results of any kind of treatment forbids 
me too strongly deciding against their use in properly selected 
cases. Nor do I think it fair to say, as has been said, that cases 
treated by internal medication and recovering are but instances of 
spontaneous cures, and would have done as well or better without 
the treatment. Dr. Denman, in his Midwifery, by Dr. Francis, 
at page 151, says: "In the beginning of this dropsy, when the 
increasing ovarium is first perceptible through the integuments of 
the abdomen, and sometimes in its progress, there is often so much 
pain as to require repeated local bleeding by scarification or 
leeches, blisters, fomentations, laxative medicines, and opiates to 
appease it. I have also endeavored to prevent or remove the first 
enlargement by a course of medicines, the principal of which was 



OVARIAN TUMORS. 443 

the unguentum hydrargyri rubbed upon the part, or calomel given 
for a considerable time in small quantities with an infusion of 
burnt sponge, or the ferrum tartarisatum or ammoniacal, trying 
occasionally what advantage was to be obtained from blisters, from 
a plaster of gum ammoniacum, dissolved in the acetum scillse, or, 
lastly, from electricity. From all, or some of these means, I have 
frequently had occasion to believe some present advantage was ob- 
tained or mischief prevented ; but when the disease has made a 
certain progress, though a variety of medicines and of local appli- 
cations have been tried, no method of treatment has been discov- 
ered sufficiently efficacious to remove it or prevent its increase." 
Colombat is of the opinion that "though we ought not to place 
much confidence in the means derived from medicine, strictly so 
called, we are of opinion that they ought always to be employed 
before recurring to those offered by surgery. Consequently, su- 
dorifics ought first to be prescribed ; for example, guaiac, sarsapa- 
rilla, and vapor baths, resolvents, and, amongst them, mercurial 
frictions, successfully employed by Clark and M. Nauche ; hydrio- 
date of potash, with the internal use of iodine in small doses; 
sea-bathing, or salt-water baths, from which M. Laennec, of 
Nantes, says he has obtained most excellent effects ; the thermal 
baths of Aix, in Savoy, or those at Barege, and, lastly, antimo- 
nial frictions, cauteries, moxas, and blisters, applied upon the ab- 
domen. Diuretics, such as squills, nitre, &c, which according to 
Haller, were usefully employed by Willis, a decoction of ashes in 
the proportion of a handful to the quart of water employed by 
Petit Radel, and from which he obtained a cure after having punc- 
tured the cyst. Lastly, purgatives in divided doses, as, for in- 
stance, aloes, rhubarb, croton oil, calomel, combined with castile 
soap and sulphate of potash, &c, are other means which, in con- 
junction with abstinence and compression of the abdomen, may be 
prescribed at the commencement of the disease for the purpose of 
assisting the absorption of the fluids, at first small in quantity." 
After trying all these, however, surgical treatment, he thinks, will 
be our only resort in a vast majority of cases. The efficient ap- 
plication of pressure seems to promise more than internal reme- 
dies. Well-regulated, efficient, and long-continued pressure may 
produce obliterating inflammation of the sacs and consequent cure; 



444 OVARIAN TUMORS. 

or, by affording great resistance to the expansion of the tumor, 
arrest its growth. 

Resolution and absorption of an ovarian tumor is a very doubtful 
fact, however, and notwithstanding their unaccountable disappear- 
ance, should not be counted prognostically. The second object in 
our treatment, that of obliterating the sac in situ, affords more 
reason for hope in properly selected cases. The means used con- 
sist of tapping, with pressure, with injections of stimulants to in- 
duce inflammation of the sac, and with injections and pressure 
combined : or, what is sometimes successful, the establishment of a 
fistulous opening in the sac that either communicates externally 
through the abdominal walls, through the vagina or rectum, or 
simply with the peritoneal cavity. The above-mentioned treat- 
ment is applicable, properly, to the unilocular or single cyst cases 
only, as it is impracticable to tap, inject, or establish a fistula 
when there are many sacs ; and what is still more discouraging in 
the multilocular variety, the sacs are not only filled again after 
tapping, as is generally the case with the monocyst, but there is a 
constant reproduction, or, perhaps, it would be more correct to say 
that they are continuously developed from the ovisacs that are 
matured every month. Tapping, followed by pressure or injection, 
is very apt to change the condition of the tumor in one respect, at 
least, and that is, to cause adhesions to the surrounding peritoneal 
surface. In one case of unilocular tumor, in which an external 
fistulous opening was made after the patient had been tapped six 
times, and had iodine injections three times, the sac, so far as we 
could determine, was universally adherent ; no portion of it could 
be brought out of the wound. 

Very fortunate instances sometimes occur in which the evacua- 
tion of the tumor by tapping is followed by a speedy and perma- 
nent obliteration of the sac. It is exceedingly doubtful, however, 
whether these were not cysts developed from the broad ligament, 
and not involving the ovarian tissues at all. Certainly, they are 
exceptional, and cannot be expected in any given case, so that we 
ought never to be satisfied with tapping when our object is the ob- 
literation of the cyst. Pressure, in conjunction with tapping, is 
applicable, perhaps, to a larger number of cases than any of the 
other modes of treatment. It is very much more successful in 
cases of the monocystic than in any other variety. The applica- 



OVARIAN TUMORS. 445 

tion of pressure to a tapped sac has for its object a complete 
closure of the cavity of the cyst in such a manner as to bring its 
walls, as nearly as practicable, in contact throughout. This at 
once, if thoroughly effected, modifies the secerning capacity of its 
surface, and perhaps, from the time of its application, arrests more 
or less completely the effusion of the fluid. Now, if this cannot 
be done so as to operate upon all the surface of the walls, we can 
almost always bring some portion of the collapsed walls in contact. 
The continuous and prolonged contact of these surfaces brings about 
a low, and in some cases a pretty high grade of inflammation, 
causing adhesion or a change in their structure, so that they are 
no longer of the same ovisac nature, and hence they do not effuse 
the thick albumen previously produced, and the tumor remains in- 
active or shrinks, and nearly or entirely disappears; or suppura- 
tive inflammation may dissolve down, and discharge the mass 
through some adventitious or natural outlet. 

The manner of applying the pressure is of the greatest impor- 
tance. The apparatus should be permanent, and exert as much 
force as the patient can bear without too great pain, fever, de- 
rangement of the abdominal viscera, or other indications of too 
acute a degree of inflammation in the cyst or damage to some organ. 
It should be applied to the tumor as nearly as possible, and the 
forcible pressure should be exerted alone upon the collapsed mass, 
so as to crowd it back against the sacrum, lumbar muscles, spine, 
and other hard parts of the posterior wall of the abdomen. In 
order to do this properly, after the fluid is evacuated as completely 
as possible, we should examine the abdomen minutely, so as to as- 
certain as clearly as possible the position of the collapsed cyst. 
This will usually be a little more to one side than the other, and 
we may generally easily define its shape and get a good idea of its 
size. We should now construct a compact compress, correspond- 
ing in shape and size with the shape and size of the evacuated sac. 
The compress should be embraced by solid wood or tin outside. 
The compress can be made of hair, gum-elastic material, or nap- 
kins. If of the latter, they should be well stitched together, so 
that there can be no shifting in their position. After attaching 
the soft portion of the compress to the hard firmly, so that any 
pressure upon the latter may be exerted unvaryingly upon the 
former, it may be placed immediately over the tapped tumor, and 



446 OVARIAN TUMORS. 

pressure applied from a direction to press it against the hardest 
part, bearing on the posterior walls of the abdomen or pelvis. An 
attentive examination of the tumor under the pressure of the in- 
strument will inform us pretty accurately as to the efficiency, com- 
pleteness, and direction of the pressure of the compress. The 
compress may be managed better by a belt of soft but firm leather, 
to surround the body in such a place as to press over the centre 
of the compress. The power and direction of the pressure may be 
regulated thoroughly and at will by subjecting it to a tourniquet 
screw pressure from the belt. Of course there must be thigh and 
shoulder straps to the belt, in order to keep it from slipping up or 
down. When we have adapted these simple contrivances, we should 
turn the screw to such a degree as to press strongly as the patient 
can bear, and with it thereafter regulate the pressure as we may 
judge best. Having thoroughly satisfied ourselves of the appro- 
priate adaptation of the apparatus, we should wrap the whole ab- 
domen agreeably tight, from pubis to sternum, with a flannel roller. 
We should every day remove the flannel" roller, and examine the 
compress and belt to be sure that they are not disarranged, and if 
in the least so, we should readapt them. We may tighten the 
screw or loosen it each time, or allow it to remain untouched, as 
the case may be. The greatest care should be taken not to pro- 
duce too great pressure with this compress. It should be loosened 
when chilliness, febrile excitement, or other general signs of dis- 
tress are added to local pain ; it may be tightened as soon as the 
symptoms decline. 

This mode of applying pressure, I think, is much more efficient 
and manageable than the plan recommended by Mr. I. B. Brown, 
the accomplished surgeon of female diseases and injuries, of Lon- 
don. His plan is to make a graduated compress of napkins so as 
to fit the top of the pelvis, and after applying it over the tumor 
so as to press it down into the pelvic cavity and against its back 
part, place over the whole a broad bandage tightly fastened from 
pubes to sternum. With this appliance we cannot always be accu- 
rate in the extent, position, and rate of the pressure, and, conse- 
quently, much more skill and experience are necessary in its appli- 
cation. Its success, hence, is much more frequent in Mr. Brown's 
hands than it has been with the profession generally. I am not 
aware that Mr. Brown teaches the necessity of pressure to all the 



OVARIAN TUMORS. 447 

collapsed tumor, but understand him to make most of his pressure 
at the origin of the tumor, — the ovarian region. The tumor, when 
collapsed by tapping after great distension, seldom sinks anything 
more than partially into the pelvis ; the long-exercised traction 
upwards generally lifts the ovary of that side above the pelvis, 
and thus we may generally somewhat accurately fit our means to 
its slope and position. An objection, Mr. Brown thinks, some- 
times applied to pressure, is the presence and great aggravation of 
prolapsus uteri. This objection, it will be apparent, is very much 
more applicable to his mode of causing it than the one I recom- 
mend. Multilocular tumors may be cured in this way perhaps 
more frequently than any other besides extirpation ; for the pres- 
sure may be made to bear upon and greatly influence the develop- 
ment of the small cysts that are not evacuated by pressure. I 
have more than once evacuated several sacs through one opening 
in the abdominal walls by partially withdrawing the trocar, and 
directing the point toward a full sac after the one first pierced had 
been evacuated. This should be attempted in a multilocular tumor 
before we use pressure ; and it is allowable, I think, to introduce 
the trocar in several places where there are a number of cysts that 
cannot be reached by the instrument from one point. I would not 
be understood as advising a reckless use of the trocar in these 
many-cysted ovarian tumors, but after we have decided from the 
circumstances of a careful examination of a given case that tap- 
ping and pressure is the treatment, Ave risk nothing, I think, in 
being thorough in our efforts to evacuate as nearly as possible all 
the sacs. — The bad effects arising from tapping and pressure are 
inflammation and its consequences. When there are symptoms of 
severe acute inflammation, the pressure should be removed, and 
leeches, cathartics, &c, should be employed to moderate or remove 
it. If the inflammation is in the sac, we should wait until all the 
acute symptoms subside before the pad or compress is placed again. 
If, however, we can satisfy ourselves that the inflammation is in 
some other part distressed by the pressure, by varying the direc- 
tion of the pressure, provided we can include the tumor under it, 
we need not wait until all the acute symptoms have vanished. I 
have a better opinion of this kind of treatment, when carefully 
managed and watched, than any other, except the complete extir- 
pation of the ovary. Another plan of obliterating the sac of ova- 



448 OVARIAN TUMORS. 

rian tumors is to first evacuate, and then inject it with some sub- 
stance calculated to induce inflammation in it, which, by its adhe- 
sive or destructive processes, may completely effect this object. A 
large number of cases are reported cured by this plan of treatment. 
For obvious reasons it is almost exclusively confined in its useful- 
ness to the unilocular variety. Under certain circumstances only 
can we expect to reach more than one cyst at a time with the tro- 
car and injections. When a cyst is simple, the patient in good 
health, and we succeed in properly managing the operation, there 
is not a great deal of danger in it, and we may reasonably hope 
for benefit from it. The most simple, and I think effective mode 
of operating, is to first draw off nearly all the fluid, except, say, 
one or two pounds, as well as we can judge of it, with a large tro- 
car. After this is accomplished, we should pass an elastic catheter 
or other flexible tube through the canula of the trocar to the 
bottom of the cavity. With a hard-rubber syringe we may inject 
the medicine, whatever that may be, through the catheter into the 
interior of the cyst. By using this elastic tube there is no danger 
of failing to carry the material to the part we desire to reach with- 
out its coming in contact with anything else, or being decomposed 
before it arrives at its destination. The formulae for this kind of 
injections are numerous, and several different substances used. 
Iodine seems now to be the substance generally employed. Dr. 
Simpson recommends several ounces of the tincture. Six ounces 
is probably enough to use at one time. I have used on several 
occasions six ounces of a mixture containing one scruple of iodine, 
two scruples of iod. potass to the ounce of water. This is cer- 
tainly iodine enough, if specific in its influence, to cure any tumor. 
My plan is to allow it to remain in the sac instead of removing 
any of it. 

Iodism is likely to occur to a slight extent, but to be the source 
of no considerable inconvenience. If it should be thought best to 
remove a part, or the whole of the iodine, the better way to do it 
is to pump it out through the tube, by means of which it was in- 
troduced, instead of squeezing it back through the canula of the 
trocar. This plan of extracting it, precludes the possibility of 
allowing any contact with the peritoneum ; which in the event of 
disarrangement of the canula, might otherwise take place. Al- 
though, ordinarily, no great amount of acute inflammation takes 



OVARIAN TUMORS. 449 

place as the effect of this injection, yet we should remember that 
it sometimes does proceed to a dangerous extent, and be upon our 
guard with the means necessary to prevent a fatal degree. In 
fact, it would be negligence on our part not to watch with solici- 
tude all the most trifling operations upon an ovarian cyst. It 
may be asked whether iodine is the best substance to use as an 
injection in such cases ? Although I have to some extent fallen 
in with the fashion of using iodine, I cannot resist the conviction 
that there are substances that would do as well, against which 
some objections that apply to iodine could not be urged. Iodine 
operates promptly upon the organism when introduced in this way, 
by being absorbed and taken into the circulation; yet, I think 
there can be but few who desire anything more than its local ef- 
fect upon the inner surface of the sac. Alcohol, wine, brandy, in 
fact any local stimulant whose general effect after absorption is 
more transient, as well as less powerful, would perhaps answer 
just as well. It cannot be that the internal effect of iodine upon 
the kidneys and other organs of excretion can enter largely into 
its good effects, for if such were the case, it would be better given 
by the stomach. Injection of iodine was regarded several years 
ago as the most eligible mode of treating this affection, because of 
its comparative safety and frequent success ; but there can be no 
doubt that it was overrated, and now the profession is less ready 
to trust it. I believe it to be both more dangerous and less effi- 
cient than pressure after tapping. This is not in accordance with 
the opinion of Dr. Simpson, I believe. I have lately known of a 
case having been treated with iodine injections combined with 
pressure. I speak of this case to warn against similar proceeding, 
for it is plain, upon a little reflection, that if the pressure is prop- 
erly applied, it will so lessen the cavity of the cyst as to endan- 
ger the effusion of the iodine, through the puncture in the sac, 
into the peritoneal cavity, and thus induce a fatal peritonitis. 
And if pressure is to be used, we should wait for two or three 
days after the injection. 

The last and doubtless most effectual plan for obliterating the 
sac, is the establishment of a fistulous opening, communicating 
with the peritoneal cavity, or the external surface, directly or in- 
directly, through the vagina or rectum. This plan is also the 
most dangerous plan, resulting in a large number fatally. Quite 

29 



450 OVARIAN TUMORS. 

a difference in the effects, both remedial and morbid, may be re- 
marked in the different places for the fistulous opening. When 
properly and carefully managed, the opening in the peritoneal 
cavity is productive of least harm, and less likely to be followed by 
a cure. The opening in the vagina is more effective, and the direct 
opening through the abdominal walls both more efficacious and 
more hazardous, than any of the others. When a communication 
is perfected and perpetuated between the cavities of the tumor 
and the peritoneum, the surface of the latter being abetter absorb- 
ing surface, the contents are absorbed, thrown into the circula- 
tion, and eliminated by excretion through the kidneys and alimen- 
tary canal. This process being carried on more rapidly than the 
secretion by the tumor, the latter is allowed to contract more and 
more, until its secreting surface is wholly lost, and indurated tis- 
sue is all that is left behind to mark its former existence. Some 
very important precautions are necessary to such happy results, 
as will appear by an attentive consideration of the subject. It is 
found, for instance, that sometimes the contents of the tumor are 
poison to the peritoneal lining of the abdomen, and therefore fatal 
inflammation may result from its effusion into the cavity. We 
cannot say without an inspection of the fluid, whether this is 
likely to occur upon performance of an operation or not, and I 
fear that we can by that means arrive at only a presumption upon 
the subject. In evacuating for the first time these growths, we 
find, occasionally, clear, transparent, good, innocent-looking fluid, 
begin to flow, when as the flow continues, the latter part looks 
darker, grumous, and ill-conditioned ; now, whether we might not 
be deceived upon inspection is a matter of question, and really 
furnish a virus to the surface of the peritoneum, instead of the 
bland albumen of the healthy ovarian tumors. However this 
may be, w 7 e do know from cases placed on record, by Dr. Simpson 
particularly, and observed, not unfrequently, that these tumors 
do sometimes burst into the abdominal cavity, and disappear, 
without any bad symptoms, so that we are justifiable in hoping 
the artificial opening may result well. Dr. Simpson recommends 
(and it is certainly the most sure way, although, as I have re- 
marked, we must under all circumstances, be in doubt), prior to 
opening communication with the peritoneal cavity, that we tap 
the tumor, and remove some of the fluid for examination, and if it 



OVARIAN TUMORS. 451 

is the ordinary bland, mucilaginous, transparent substance found 
generally after first tapping, he assures us we may proceed to the 
operation unhesitatingly, or rather, may keep the puncture in the 
sac open afterwards, instead of allowing it to close up, as it usually 
does. This is done by, in the first place, not removing nearly all 
the fluid from the sac by tapping, but allowing enough to remain 
to keep it partially distended ; and in the second place, every 
twenty-four hours so to press upon the tumor as to well up the 
fluid through the .opening in the sac, and thus break the slight 
adhesions which may have formed between the edges of the wound, 
and allow it to escape into the peritoneum. Dr. Simpson thinks 
this is the safer way, so far as the danger from the operation is 
concerned, but as will be seen, not so certain of accomplishing 
the object. He has cured cases in this way. The most effectual 
and the most dangerous way is, to cut down upon the tumor, and 
remove a piece from its wall large enough to insure patency, with- 
draw a part of the fluid, and then close the wound in the abdomen, 
and allow the rest of the fluid to flow into the peritoneal cavity 
thence to be absorbed. The immediate danger in this operation 
is, that of dividing some of the bloodvessels which ramify through 
the walls of the tumor, and thus allow internal hemorrhage to 
take place. To avoid this, it is recommended by Mr. Brown to 
draw out, examine, and divide, only that portion which is clear of 
vascular ramifications. Others have recommended to tie any 
branch large enough to bleed. There is but little doubt that the 
precaution recommended by Mr. Brown would be sufficient to 
avoid that difficulty. The large wound through the peritoneum 
makes the chance of inflammation in that membrane greater than 
the mere puncture of the trocar. Upon the whole, I think I 
should prefer Dr. Simpson's plan of keeping the opening made 
by the trocar in the tumor patent, by frequent well-directed 
manipulation. It ought to be practised I think oftener than 
every twenty-four hours ; as often as every twelve, for the first 
two days. It will probably be found upon extensive trial, that it 
may not always be practicable. Should there be adhesion at the 
point where the trocar passes, it would necessarily fail. 

The plan for making a fistulous opening externally, is more prac- 
ticable perhaps than the one just detailed, from the consideration 
that it is more manageable. 



452 OVARIAN TUMORS. 

The operation is simple, and not attended with much immediate 
danger; the danger coming in the shape of acute inflammation 
soon after the operation, or exhausting suppurative inflammation 
and its attendants. Mr. Brown, who has given it a more exten- 
sive trial than anybody else, selects a point midway between the 
umbilicus and the anterior superior spines of the ilium of the side 
in which the tumor originated. His plan is to make an angular 
incision at this point down to the peritoneum, dissect up the angle 
from that membrane so as to completely expose it, evacuate the 
tumor through this exposed part with a trocar, stitch the sac to 
the sides of the opening, enlarge the puncture in the cyst, and 
keep it open by a pledget of lint or other substance as he finds 
most convenient. Others cut down to the peritoneum, at a point 
midway between the umbilicus and symphysis pubis, stitch the sac 
to the sides of the wound, and keep open by lint or stomach-tube. 
Care should be taken, especially if the contents of the sac should 
have a suspicious appearance, to prevent it escaping into the peri- 
toneal cavity. Often there is adhesion at this part, when the 
stitches will not be necessary. This opening should be kept pat- 
ent until the cavity of the cyst is lost by contraction, inflamma- 
tory adhesion, or granulation, or all these combined, which is 
probably the common mode of their disappearance. Some diffi- 
culty will be found in doing this, there is such a strong tendency 
in the wound to contract and heal up by granulation. If neces- 
sary, we may from time to time somewhat enlarge it with the 
knife, and we should not allow it to close until the discharge has 
entirely ceased. From what I can see of the dangers of this 
operation, they are very little, if any, less than from ovariotomy; 
and I should not feel induced to resort to it, unless it were in a 
simple cyst, where tapping, injection of iodine, or the use of pres- 
sure had entirely failed, or where after exposing the cyst ovariot- 
omy was found impracticable, from extensive adhesions. This 
I have done in one instance. The adhesions were so extensive, 
that the cyst could not be removed, in fact, they seemed to be 
about universal; the incision was small, only admitting two fin- 
gers; the sac had adhered at the point where the opening was 
made, so the incision was all that was necessary in the way of an 
operation. The patient died of acute peritoneal inflammation in 



OVARIAN TUMORS. 453 

three days afterwards. A post-mortem examination revealed ex- 
tensive inflammation of the sac and peritoneum. 

Professors Kiwisch and Scanzoni, of Wurtzburg, are "warm ad- 
vocates of a fistulous opening through the vagina into the tumor, 
to be kept open until the same obliteration takes place that was 
spoken of as occurring in the case of opening through the front 
walls of the abdomen. Scanzoni operated on fourteen cases: 
eight resulted in a perfect cure ; in two, the fluid collected again 
in a few weeks, one died of typhus fever two months after, and 
three were lost sight of. In none of the fourteen did death occur 
as a consequence of the proceeding. He mentions one case only, 
in his whole experience, in which death occurred from peritonitis, 
and that was Prof. Kiwisch's case. Scanzoni admits its danger, 
but shows quite a favorable opinion of it. Dr. West gives three 
cases of his own, two of which were cured, but had formidable in- 
flammation; the third died, not as an effect of the operation, but 
from something else, which he does not state. Scanzoni taps with 
a trocar through the vagina, and allows the canula to remain 
until the cure is effected.* This, of course, occupies a variable 
time; the tube is withdrawn by Scanzoni by the eighth or tenth 
day in some cases. He says that some of his cases recovered 
without any sign of inflammation, or other inconvenience. Dr. 
West operates by introducing the trocar, and withdrawing the 
fluid, passing a number twelve catheter through, and removing 
the canula over the catheter. The catheter is allowed to remain 
until the cure is complete. Simple cysts are the only kind that 
can be cured by the fistula method, and the recommendation to 
tap once, to be sure that there is but one cyst, is a good sugges- 
tion. The cyst cannot always be reached from the vagina, and 
only in such cases as it is crowded down into the pelvis, so as to 
give obvious fluctuation in that canal, should we think of this 
operation. 

The third object in the treatment, partial or complete removal 
of the diseased mass, remains to be considered. Could the tumor 
always be removed when the operation is once commenced, one of 
the greatest objections to ovariotomy would be removed, and the 

* The only case I have operated on in this way died of pyaemia from suppura- 
tion of the cyst. The canula remained for fifteen days. 



454 OVARIAN TUMORS. 

question of the propriety of attempting it would be very much 
simplified ; but, unfortunately, the operation cannot Only not be 
finished in many instances when attempted, but it is utterly impos- 
sible in our present state of knowledge to predict with the most 
favorable opportunities whether difficulty will arise or not. The 
only obstacle worth considering, if not the only one, to completion 
of the operation of ovariotomy, is the adhesion of the tumor to 
the abdominal walls or viscera so strongly and largely that it is 
impossible to separate them, and if separated, to add very much 
to the dangers of inflammation. This obstacle and its dangers are 
so great as to entirely deter many courageous surgeons from per- 
forming ovariotomy, or allowing it to be considered a legitimate 
operation ; but, notwithstanding the above facts, when confined to 
appropriate cases, with appropriate tentative measures, care, and 
the avoidance as far as possible of the objectionable features of the 
operation itself, in the modes of performance more particularly, 
and the desistance from or change in the operative procedure 
when much adhesion exists, I should unhesitatingly advise a re- 
sort to it. 

Some of the effects which generally intervene between the sur- 
gical violence of the operation and fatal termination are, 1st, peri- 
toneal inflammation ; 2d, hemorrhage from the peduncle ; 3d, 
pyaemia ; 4th, abdominal shock ; 5th, exhaustion. 

The danger from the above conditions is somewhat in compar- 
ison with the order in which they are named. The most danger 
is to be expected from peritoneal inflammation, next from hemor- 
rhage, &c. Now, an operation ought never to be performed when 
possible to do otherwise, in such a manner as to increase the risks 
of any one of the above conditions. Everything should be avoided, 
so far as at all practicable, that irritates the peritoneum in any 
shape; perfect security from hemorrhage should be an indispens- 
able consideration. It is not supposable that with every possible 
improvement the operation will ever become safe, but there is 
every rational position in favor of the assumption, that many 
deaths may be avoided by thus rigidly adhering to a determina- 
tion to leave nothing undone to lessen all the above-mentioned 
causes of death. Success in a great undertaking, notwithstanding 
bad management, should not encourage us to hope for a like purely 
fortunate result. The more good sense and science we can com- 



OVARIAN TUMORS. 455 

bine in an operation, the more likely we will succeed. Many good 
men do things they know hazardous, ivhen they could as well avoid 
them, because they have been successful in the same way before. 
Dr. Tyler Smith read four cases of ovariotomy before the London 
Obstetrical Society, which are published in the Lancet, for Sep- 
tember, 1861, in one of which he says : " The ligatures and stump 
were cut off as closely as possible, and the whole returned into the 
pelvis, with the expectation that they would be quickly enveloped 
in coagulable lymph, so as to prevent injury. The patient recov- 
ered without a single bad symptom, taking no medicine but thirty 
drops of laudanum." This woman recovered well, and will justify 
similar procedure when unavoidable, but the treatment was bad, 
and cannot be justified. Mr. Spencer Wells very justly repri- 
manded him for it in a gentlemanly way, by saying that the pro- 
cedure ought not to be imitated without more discussion. Before 
undertaking to avoid or prevent any of these untoward circum- 
stances which result from ovariotomy, it will be necessary to ex- 
amine more at length the immediate causes of them. And first of 
peritoneal inflammation. One of these causes, to a great extent 
unavoidable, is exposure of the peritoneal cavity to the contact of 
air, and, in many instances, unnecessary handling or contact with 
the fingers, sponges, cloths, &c. The greater in amount, the longer 
duration either of these sources of irritation are applied, the more 
danger, notwithstanding immunity observed in cases where both 
were extreme. If contact of the atmosphere is slight, and its 
duration short, we must have less danger to apprehend than if the 
whole abdominal cavity were exposed for a long time; and it cannot 
be a philosophical conclusion that a small wound, two inches long, 
exposing but a small extent of the peritoneum, open but ten min- 
utes, is as dangerous as an incision from sternum to pubis open 
for an hour. Much less is it rational to handle all the viscera, 
wipe them, and return them into the abdomen, and perhaps sponge 
out the whole cavity. That women have recovered from such rash 
acts is no reason why they are proper or allowable when it is pos- 
sible to avoid them. While this kind of causes of peritoneal in- 
flammation cannot be wholly avoided, all that is possible should 
be. The incision should be no larger than necessary to permit the 
extraction of the collapsed tumor, and the hand should never touch 
the peritoneum when adhesions do not make an enlargement of the 



456 OVARIAN TUMORS. 

incision necessary and the introduction of the fingers indispens- 
able; then the enlargement of the opening should be carried to 
the least possible degree, and the handling as slight as necessary 
to accomplish the object, either to separate the adhesions, or satisfy 
us that this is impracticable. Perhaps the return of the ligature 
into the abdomen is fraught with more danger than any other of 
the ordinary parts of the operation. Its contact with the perito- 
neum will irritate it, and awaken inflammation, unless in very for- 
tunate cases it is surrounded with fibrine, and thus the danger 
averted. It should be remembered, however, always, that it is a 
danger averted, and that the limit of the inflammation is the aver- 
sion of the danger, and that the presence of the ligature is the 
danger. The inclusion of the ligature, although it may not light 
up extensive and rapidly fatal peritonitis, as a focus of phleg- 
monous inflammation may generate pus enough to poison the blood, 
and induce pysemic fever and exhaustion. It is most likely that 
pyaemia results more frequently in this than any other way. But 
the inclusion of the ligature is the cause of the next most frequent 
condition effecting death, after ovariotomy, that is, hemorrhage. 
However secure the ligature may be applied apparently, there is 
no certainty that bleeding will not occur from the peduncle. 

Dr. West introduces a table which, perhaps, shows the subject 
in its proper proportion. In fifty-nine cases, 

29 proved fatal from peritonitis. 



3 f 


1 " hemorrhage. 


8 


' " exhaustion. 


2 ' 


' " shock. 


3 < 


1 u abscess. 


2 ' 


1 " ulceration of intestines. 


1 


1 " tetanus. 


1 < 


' " phlebitis. 



59 

It will be seen that a large proportion of the deaths occur as the 
consequence of hemorrhage in the peritoneal sac ; the patient 
bleeds to death internally. But if the hemorrhage should not be 
great enough to exhaust and cause death as a hemorrhage, as an 
irritating substance it may produce peritoneal inflammation, and 
in that way cause death. Ulceration of the intestines, in conse- 



OVARIAN TUMORS. 457 

quence of the ligature lying in contact with them, is another evil, 
resulting from the presence of the ligature in the abdominal cavity. 
The principal objections to the ligature, and which should warn us 
against its use either internally or externally, are, that it causes 
peritoneal inflammation by lying in contact with it in the cavity ; 
by inducing strangulation and sending forth the inflammation 
along this very susceptible membrane, thus causing it to become 
general ; by inducing phlegmonous inflammation, exhausting ab- 
scess, and, perhaps, also causing pyaemia ; and, lastly, the great 
uncertainty in securing the vessels of the stump against hemor- 
rhage. I regard the dangers here mentioned against the ligature 
as adding so much hazard to the operation that I could not think 
of making use of it, unless it seemed entirely indispensable in the 
particular case. More can be done, fortunately, to prevent peri- 
toneal inflammation and internal hemorrhage than any other con- 
ditions which are found to prove fatal by their presence. The 
shock which succeeds the operation, now that chloroform can be 
made to shield the nervous system against the effects of such ex- 
tensive violence, is not so much to be feared, but should always be 
carefully guarded against. If inflammation and hemorrhage can 
be prevented by improvements in the operation, even in fifty per 
cent, of the cases, fatality will be very materially decreased. 
Whatever may be the teaching of experience as to the tolerance 
of and recuperation from violent and rash procedure in the per- 
formance of so dangerous an operation, it cannot justify us in 
making use of means or methods that common sense, physiology, 
and pathology, all combine in declaring more hazardous than 
other means and methods which we can employ. Let, therefore, 
no more incision and exposure, or handling of the viscera, be al- 
lowed than is absolutely necessary to extract the collapsed tumor, 
and discard scrupulously the ligature and clamp. After so much 
of an introduction by way of expressing my conviction that too 
much preventive measures cannot be employed, and that the oper- 
ation is too often more hazardous than it need be, by following 
the examples of men who have succeeded in spite of rashness and 
carelessness, I am ready to describe what I consider the best 
method of operating. The best time for operating is about the 
middle of the menstrual month of our patient, and if consistent 
with the circumstances of the case between the first of October 



458 OVARIAN TUMORS. 

and the first of June in this climate ; but, of course, all will de- 
pend upon the urgency of the symptoms in the case as to this last 
item of time. The patient should not be too much prepared, as it 
is easy to get up functional disturbance, and thus with medicines 
intended to place the patient in more favorable condition for oper- 
ation, get the system in a state the least calculated to resist the 
attack of traumatic disease. Above all, we ought not to disturb 
the abdominal organs with a cathartic ; and if the stomach, liver, 
or other organs require a purgative, it should be given three or 
four days before the time to operate, and we should give them 
time to recover their tranquil tenor of function before we venture 
upon it. Should the bowels be constipated, we may give an enema 
six or eight hours beforehand, but not oil or other cathartics. It 
is good practice to give a pretty full dose of opium an hour before 
we put the patient upon the table. This is all the preparation she 
needs, provided she is in good condition of general health. Of 
this last we should be sure when practicable. We should at least 
satisfy ourselves that there is no predisposition to the suppurative, 
erysipelatous, or inflammatory diathesis. For three hours she 
should be in a state of perfect physical and mental tranquillity, if 
possible to secure it, and at the time placed in a perfect anaesthetic 
condition before being removed from her bed, and without seeing 
any of our preparations. We should be prepared by carefully 
passing in review the successive steps of the operation minutely 
and deliberately, performing the operation mentally first, making 
provision for all possible complications or embarrassments, and 
carefully placing everything we shall need, as suggested by this 
kind of reflection, just where it can be most handily available. We 
should next state to our assistants what we expect to do in each 
successive step in the operation, and the part we desire them sev- 
erally to perform under all given circumstances and times of the 
operation. This complete understanding between all the parties 
who partake with us in the operation, will preclude the danger of 
confusion and possible imperfection in the procedure. We want a 
good scalpel, blunt-pointed bistoury, large trocar, two large liga- 
tures in needles, an ecraseur, half a dozen silver pins, three inches 
long, with movable steel points to them, several large waxed liga- 
tures, three or four small needles, armed with silver wire, a tenac- 
ulum, silk for artery ligatures, and it is well to have small artery 



OVARIAN TUMORS. 459 

forceps. This will constitute a pretty full operative armament. 
We shall also want two or three fine sponges of different sizes, a 
flannel roller large enough to make a binder for the patient, one 
pan of cold and one of warm water, some adhesive plaster, and 
old cloths of linen for compresses. Our table should be firm, 
about two feet wide, six feet long, and conveniently high, covered 
with sufficient soft quilts not to be too hard, and placed near the 
lightest part of a large and airy room, brought to a temperature 
of about 70° Fahrenheit. When all the above preparations are 
made, we are ready to operate. We should have at least three in- 
telligent physicians as assistants, — one to act as main assistant, 
one to use the chloroform, and one as general handy man. 

Supposing our diagnosis to be as complete in all respects as pos- 
sible, especially with reference to the nature of the contents of the 
tumor and the adhesions, &c, we may cause the bladder to be evac- 
uated, etherize and place our patient, on the table, on her back, 
with the limbs hanging over one end to the knee. We should 
stand at the end of the table in front of the patient, when the large 
protuberant abdomen will rise before us, and the part below the 
umbilicus be completely exposed. With the scalpel, the operator 
should make an incision in the linea alba, midway between the 
umbilicus and symphysis pubis, about two inches long, through the 
walls of the abdomen down to the tumor, but he should avoid open- 
ing the cyst with the knife. It will require some care to avoid the 
cyst, particularly as the aponeurosis is thin at this place. The 
strokes should be light, and an examination made for the perito- 
neum after each touch of the knife, as soon as near the proper depth 
has been reached. When the sac is exposed, we should plunge the 
trocar into it and evacuate it, and, so far as possible, extract it 
through the wound. If the tumor is multilocular this procedure 
will soon bring another cyst to the incision, when it should be 
punctured and evacuated and thrown out through the wound, the 
next punctured, &c, until the whole is reduced sufficiently in size 
to be drawn entirely out. Should there be a solid portion at the 
base of the tumor so large as not to come out of the wound easily, 
we may enlarge the latter sufficiently. We occasionally meet with 
instances in which the contents of the different sacs are so thick 
and tenacious that they will not flow through a canula of any size. 
It would be improper, when found thus thick and gelatinous in 



460 OVARIAN TUMORS. 

consistence to continue our efforts to evacuate them, but we should 
enlarge the wound sufficiently to remove the whole mass, there 
being less risk in this procedure than to allow the peritoneal 
cavity to be irritated by the contact of such material in the vain 
hope of getting it entirely away. All this being done, the tumor 
lying outside the abdomen, the pedicle passing through the open- 
ing should be pierced on each side with one of the needles, with 
the large ligature as near as possible to the tumor. This is for 
the purpose of giving us perfect command of the stump after the 
tumor is separated. If the peduncle is thin, the chain of the ecra- 
seur should now be thrown around it at the base of the tumor, leav- 
ing the stump as long as possible, and slowly crushed through it. 
We should next place the stump in the wound, leaving its edge a 
little above the level of the skin, and by means of the silver pins 
one inch apart surround them with the thread, and secure perfect 
adaptation of the lips of the wound. The pins should be made to 
enter the skin about an inch from the edge of the incision on one 
side, dip down as near to the peritoneum without touching it as we 
can well effect, and, piercing the opposite lip, come out about an 
inch beyond the other side of the wound. If the edges gape at 
all, some superficial stitches with the fine silver wire should close 
this more completely. A compress of wet lint should be placed 
over the wound, and all surrounded by the flannel roller, the pa- 
tient removed and placed in bed, and allowed to come from under 
the effect of the chloroform. This operation is simple, easily per- 
formed, and, I think, inflicts as little dangerous violence, if not 
less, than any other operation the details of which are given. 
The extent of the wound is the least possible for the purposes of 
it. No handling or even rough contact of the viscera is required. 
The peritoneal cavity is exposed in the smallest extent, and for 
the shortest time, and all the objections and dangers urged against 
the ligature around the stump or in the abdominal cavity are ob- 
viated and avoided. The separation of the peduncle with the 
ecraseur, and the placing the edge outside the wound, so that if 
hemorrhage does occur it is outside, and is within the control as 
well as observation of the medical attendant, lessen, it seems to 
me, very materially the causes of inflammation at least, and as a 
logical, if not actual sequence, the dangers of the operation. 
When the peduncle is thick or vascular, particularly the latter, 



OVARIAN TUMORS. 461 

we ought not to trust to the ecraseur merely, but the stump ought 
to be embraced in a clamp. This instrument may be found made 
by most of our instrument-makers. It consists of two light steel 
bars, about four inches long, serrated on the sides intended for 
coaptation. These two steel bars are placed one on each side of 
the peduncle close to the tumor, approximated and held firmly toge- 
ther by one screw at each end passing through them. The screws 
are tightened sufficiently to prevent hemorrhage, and the whole 
left outside the wound, when this last may be closed as before rec- 
ommended. The most convenient way of arranging the clamp is 
to turn it across the wound, and, when the peduncle is long enough, 
to place it at the lower angle. 

But sometimes the attachment is so very short that it is not 
practicable to bring the stump out of the wound. When such is 
the case, we may pass a needle armed with a double strong hempen 
ligature, and tie it very tightly on both sides of the peduncle, cut 
oft", and drop it back into the cavity of the abdomen, leaving the 
ligature through the lower angle of the wound. We may then 
close it as before recommended. 

Yery many cases, however, which promise to be favorable for 
the above procedure, so far as we can judge from examination be- 
forehand, as we proceed in the operation we will find cannot be 
terminated without much more difficulty, and, in some, our pro- 
cedure must be very materially varied from the above detailed 
plan. 

The main and almost only obstacle to the performance of this 
operation is adhesion of the tumor to the abdominal walls or vis- 
cera. The amount and firmness of adhesion will determine the 
extent and nature of the varying steps. The incision through the 
abdominal wall should be the same in all cases, and unless adhe- 
sion be at the point where the incision is made, I would evacuate 
the presenting cyst, and remove it through the opening as far as 
practicable, and if the adhesions were small and easily overcome, 
do so by traction, or if to the intestines or omentum, they might 
be separated, after bringing them under the eye through the 
wound, and we should thus proceed to evacuate separate cysts as 
far as practicable. Should this plan prove ineffectual after perse- 
vering trial, the opening should be enlarged to four or five inches 
in extent, and then a careful and thorough inspection of the con- 



462 OVARIAN TUMORS. 

dition of the adhesions be made. When adhesions are present we 
find them, 1st, in long bands of false membrane, reaching from the 
abdominal walls to the tumor ; 2d, delicate flat adhesions, fasten- 
ing the omentum to the tumor; or, 3d, close, firm adhesions of 
'the flat surface of the abdominal walls to the sides of the tumor. 
When a tumor grows rapidly, the adhesions are apt to be drawn 
into long bands. These bands are sometimes so tough that great 
force is required to separate them. They are sometimes four or 
five inches in width, and thick and strong. They may be sepa- 
rated by the ecraseur. I should not think of tying them, as they 
are poorly supplied with vessels, and separation by this instrument 
is sufficient to prevent hemorrhage. Not unfrequently there are 
five or six of these bands. The second sort of adhesions are next 
in frequency to the first. The adhesions of this form should be 
overcome by the fingers. The fingers may be passed between 
the tumor and omentum, and with great gentleness overcome. 
We can often do this at the points of attachment without tearing 
the vessels or substance of the omentum. Should any vessels 
bleed, we may tie them with fine silk ligatures and cut them close. 
The broad, flat adhesions between the peritoneal covering of the 
tumor and the walls of the abdomen occur in tumors of slow 
growth, and are the least frequent and most difficult to manage. 
They may be so loose that we can tear them apart. When this is 
practicable, it is very much the best mode of overcoming them. 
But often they are so firm that the peritoneum would be separated 
in the attempt to do this. When such is the case, we may cut them 
off at the edge of the attachment with a knife or scissors, being 
careful to look for any source of hemorrhage, and tie it when 
found. Ordinarily, the inflammation which caused the adhesions 
also closes the vessels in such a way as to make them less liable to 
hemorrhage. If it should be practicable to withdraw a consider- 
able portion, or even if not, we should lay open that part at or 
outside the incision, and turn the sides over each edge of the 
wound, and through the incision in the cysts try, and if possible 
evacuate the fluid from all the remaining cysts, and in this way as 
perfectly collapse the tumor as possible. If practicable, we ought 
not only to puncture the cysts that we cannot remove in this way, 
but remove a part of the partition between those remaining, so as 
to convert them all into one cavity. We should now separate all 



OVARIAN TUMORS. 463 

the tumor outside with the ecraseur, first securing it so that the 
portions remaining do not pass beyond our reach into the abdom- 
inal cavity. Bringing the edges of the amputated sac above the 
surface, it should then be secured by the pins, as in the first pro- 
ceeding, and the wound should be closed up, except to the extent 
of half an inch at the lower angle, which should be kept open by 
lint, or the insertion of a flexible tube. If none of the sacs can 
be removed after puncturing and destroying as far as possible the 
partitions, we should keep the wound open as above directed. The 
after treatment should have reference to the danger from the 
shock, from which the system may not recover itself. Peritoneal 
inflammation is by far the most dangerous; and where a part or 
the whole of the tumor is left, inflammation of the cysts or hemor- 
rhage from the amputated stump. 

Mr. Brown recommends small pieces of ice in the mouth to suck, 
as one of the means preventive of inflammation ; and as they are 
very grateful, particularly the second day, I would join him in it. 
The bladder must be watched, and evacuated at least every eight 
hours. If the patient can do this spontaneously, it is well ; if not, 
the catheter ought to be resorted to. Every two or three hours 
the dressing in the region of the wound should be inspected, lest a 
slow but exhausting hemorrhage occur, and the chances of our 
patient be lessened. 

There cannot be any very definite directions given as to the 
treatment of inflammation, or any other of the effects of the opera- 
tion, other than may be found with reference to them in any well- 
digested treatise upon the subject. 

We must be watchful to perceive the very beginning of them, 
and energetic in the treatment. An incipient inflammation may 
be subdued much easier than a well-established one. In institut- 
ing measures to combat inflammation or any of these effects, we 
must carefully consider the condition of our patient, there being 
no question that tonics and even stimulants, with anodynes, are 
better adapted to cure inflammation than depletion in patients of 
this kind under certain circumstances. It is only in the young 
and robust, well nourished at the time, that depletion can be ex- 
tensively used; in moderation, when early used, there are but few 
who will not be benefited by it, even when we must follow it with 
quinine and stimulants. There are a few chronic cases in broken- 



464 OVARIAN TUMORS. 

down constitutions, emaciated, highly debilitated, and particularly 
dyspeptic, with depraved secretions generally, that we must sus- 
tain from the time of the completion of the operation, in order to 
prevent inflammation and exhaustion, one or both. 

In illustration of the after treatment of and the course pursued 
by these cases after the operation, I subjoin three cases. 

Case 1. Mrs. H , aged 38 years, has been gradually increas- 
ing in size with ovarian dropsy : for the last four years. She first 
observed a small tumor in the right iliac region. Before removal, 
it filled up the pelvis and abdomen, until the patient was as large 
as at full term of pregnancy. Her suffering for several months 
had been very great, on account of impaction of the pelvis, and 
her general health" was rapidly deteriorating. The tumor was 
multilocular, and, with its contents, weighed nineteen pounds. 

The operation for its extirpation was performed in presence 
and with the assistance of Drs. Shumway, Cheeney, Davis, Bevan, 
and Jones. An incision between three and four inches in length 
in the linea alba, about equal distances from the umbilicus and 
pubis, enabled us to draw off the contents of the numerous cysts 
with the trocar, and extract the whole tumor with great facility 
and despatch. The pedicle was transfixed by a needle carrying a 
large double hempen ligature, and tied in two parts firmly as I 
could draw the twine. The wound was closed by three silver pins, 
the lower of which was passed through the middle of the pedicle, 
so as to confine the cut edge upon a level with the skin of the ab- 
domen. I should have mentioned that, after being tied, the pedi- 
cle was divided between the ligature and the tumor with the knife. 
When the tumor was first exposed, there were within view, ramify- 
ing over its surface, a number of large veins; several of them were 
larger than a goose-quill. The pedicle was large and fleshy, show- 
ing several large venous trunks. There were no adhesions any- 
where; and the only obstacle to a ready removal of the tumor, 
when lessened by evacuation, was caused by a cyst that completely 
filled up the cavity of the pelvis. It was so completely moulded 
into the inequalities of that cavity, that some force and address 
in manoeuvring were requisite to lift it out. The wound was 
covered with a water compress, and the abdomen encircled with a 
broad woollen binder. The operation and dressing were finished 
in eighteen minutes after the patient was completely under the 



OVARIAN TUMORS. 465 

influence of chloroform. Dr. Shumway, whose patient she was, 
and to whom much credit is due, for his assiduity and skill in the 
after-management of the case, kept full and accurate notes; they 
are highly interesting on several accounts, and will be read with 
profit by those who are studying the subject. They are sub- 
joined. 

Operation was completed at 3 o'clock and 33 min., Oct. 29th. 
4 p.m., vomited once a little water; pulse 76; complains of smart- 
ing pain at seat of wound, and severe pain in the bowels, "like 
the pain of colic;" ordered tinct. opii, gtt. 40. 6 p.m., much 
more comfortable; says that she has not a particle of pain in the 
right side, but complains of pain in the left hypogastric region 
and down the left thigh; pulse 88, full and soft. 6.30 p.m., pain 
continuing, gave tinct. opii, 30 gtt. 8.30 P.M., still complains of 
severe pain in left hypogastrium and thigh ; pulse 88; gave tinct, 
opii, 40 gtt. 11.30 p.m., patient easier; has slept, with a few min- 
utes' intermission now and then, since 9 P.M.; pulse 88, as before. 
12 P.M., return of pain; gave tr. opii, 30 gtt. Thursday, 30th y 
3 a.m., used catheter, at patient's request; comfortable; pulse 
88. 9 a.m., pulse 90, full and soft; complains of return of pains 
in the left thigh; gave tinct. opii, 30 gtt. 12 M., complains of 
thirst, otherwise very comfortable; ordered ice, ad libitum; re- 
peat tr. opii, 30 gtt. 3 p.m., symptoms unchanged; relieved 
bladder with catheter; tinct. opii, 30 gtt. 5.30 no change, pa- 
tient comfortable. 9 p.m., patient cheerful; ordered tr. opii, con- 
tinued every three hours if she is restless or complains of pain. 
Friday, 31st, 8.30 a.m., found patient comfortable ; has slept at in- 
tervals during the night; pulse 95; skin cool; does not complain 
of pain, except a slight smarting at the seat of wound ; catheter. 
8.30 p.m., finds patient feverish ; pulse 100; countenance anxious; 
skin dry and hot ; very restless and irritable ; much troubled by 
secretion of mucus in the trachea, with desire to cough ; slight 
fulness of the abdomen; had taken 40 drops tinct. opii ; at 4 P.M., 
ordered 40 drops more ; as she was still unable to pass water, her 
bladder was relieved by use of catheter. 10 p. M., less bronchial 
irritation ; continue tr. opii, 30 gtt. every three hours. Satur- 
day, Nov. 1st, 8.30 a.m., more comfortable ; pulse 96, softer and 
fuller ; has slept at intervals during the night ; tympanitis in- 
creased; ordered em. terebinth.; continue tr. opii. 12 M., con- 

30 



466 OVARIAN TUMORS. 

siclerable tympanitis ; complains of pain in the bowels, with de- 
sire to go to stool ; upper part of the wound looking well ; slight 
phlegmonous inflammation about the pedicle ; pulse 100 : continue 
em. terebinth, and tr. opii. 6 p.m., tympanitis increased, but 
less tenderness over the abdomen than there was last night ; more 
cheerful ; pulse 96, soft and full ; gave 5 grs. calomel : continue 
em. terebinth, and tr. opii, with b. c. soda. Sunday, Nov. 2d, 
8.30 a.m., found patient cheerful; she says that" she is almost 
well, and meant to have had her clothes changed before the doctor 
came;" nurse was engaged making her toilet; ordered all opera- 
tions of that kind to be suspended ; pulse 100 ; tympanitis in- 
creased, but no tenderness over the abdomen; continue em. tere- 
binth., tinct. opii, and perfect rest. 4 p.m., found patient much 
worse ; was taken soon after we left in the morning with severe 
pain in the left hypogastrium ; pulse 128, small and quick ; skin 
hot and dry; tympanitis or flatulence much increased; gave tr. 
opii, 40 gtt., and ordered enema of 

01. -Terebinth., jfss. 

01. Eicini, gj. 

Yolks of two eggs, 

Gruel, . . Oj. M. 

6p.m., enema retained; gave another of soapsuds, which brought 
away a large amount of gas, but no feculent matter ; pulse 120 ; 
pain subsided ; abdomen tender ; wound looking tolerably well ; 
union appears firm at the upper part ; considerable phlegmonous 
inflammation about the pedicle; ordered the em. terebinth, and tr. 
opii, continued every three hours, and one grain sulph. quina to 
be added to each dose, and the abdomen covered with a poultice 
of flaxseed meal, after being rubbed with ol. terebinth., care 
being taken not to get any of the oil into the wound ; gave fl. ext. 
rhei and senna, 3ij- Monday, 3d Nov., 8.30 a.m., patient rested 
tolerably well through the night ; pulse 116 ; abdomen very much 
distended ; wound firmly united at the upper part, but looking un- 
healthy about the ligatures ; cut the ligatures, and removed two 
of the needles ; a serous discharge followed the withdrawal of the 
needles ; ordered beef-tea and milk-punch freely ; pinned a band- 
age tightly around the abdomen ; she does not complain of pain 
upon pressure ; repeat fl. ext. rhei et senna. 12 M., abdomen 



OVARIAN TUMORS. 467 

enormously distended ; patient restless ; pulse 120 ; gave enema, 
which brought away a large amount of gas, which much relieved 
the distension of the abdomen ; repeat the rhei and senna. 6 
P.M., pulse 120 ; distension very great; applied adhesive straps to 
support the wound ; complains of no pain or tenderness ; bowels 
have not moved ; ordered enema, which only brought a discharge 
of gas; gave 12 grs. calomel. Tuesday, 4th, 8.30 a.m., bowels 
have not moved; pulse 116; only complains of the distension of 
the abdomen ; ordered bot. citrate magnesia. 2 p.m., the bowels 
not having moved, gave enema of ol. terebinth., which produced a 
free movement of the bowels, with discharge of a large quantity 
of gas, almost entirely relieving the -abdominal distension. 5.30 
P.M., patient expresses herself as "almost well;" pulse 108; skin 
cool; ordered injection repeated in three hours if the bowels do 
not move again in the meantime; continue milk-punch and beef- 
tea, and give tinct. opii, 30 gtt., after the bowels move again. 
Wednesday, 5th, 9 a.m., the injection last evening produced a 
complete collapse of the abdominal wall ; patient slept nearly all 
night, — is very comfortable this morning ; pulse 106 ; no pain ; no 
tenderness, except at seat of wound. 5 p.m., improving steadily. 
Thursday, 6th, 8.30 a.m., pulse 100; no unpleasant symptoms; 
wound around the pedicle discharging freely; takes considerable 
nourishment. Friday, 7th, same as above. Saturday, 8th, re- 
moved the remaining needle which transfixed the pedicle, — liga- 
ture firm. Sunday, 9th, wound looking well ; patient looking and 
feeling very well, — appetite good. 

Case 2. I was called, Nov. 5th, 1862, to see Miss P., aged 20 
years, at Eleroy, Illinois, suffering with ovarian dropsy. There 
had been nothing remarkable in the condition of her health, al- 
though of rather spare and fragile form, until February last, when 
she first observed a tumor, almost the size of an orange, in the 
right iliac region. Her menses ceased to make their regular ap- 
pearance about the same time. The tumor had grown quite 
rapidly, and she had suffered several weeks severely from pressure. 
At the time of examination, she seemed larger than most women 
at full term of pregnancy. The patient was examined by, and in 
consultation with, Drs. L. A. Mease, B. J. Buckley, F. W. Hance, 
E. C. De Puy, and John Charlton, of Freeport, Dr. R. Hayes, of 
Lena, and Dr. J. A. Darling, of Eleroy. It was unanimously de- 



468 OVARIAN TUMORS. 

cided that the tumor was multilocular; and as it had grown so 
rapidly, and the patient had begun to suffer from its great size — 
she could not long survive if not relieved — that extirpation was 
the only means of cure advisable, and that owing to the probabili- 
ties of a large portion being solid, and the existence of adhesions, 
the chances of success were less than ordinary. The conclusions 
of the consultation being submitted to the patient, with a heroic 
determination that I think had much to do with her recovery, she 
begged us to give her what she considered the only chance of es- 
cape from a lingering and sure death. With the assistance of the 
above-named gentlemen, the operation was performed in the fol- 
lowing manner : After anaesthesia was induced by chloroform, an 
incision in the linea alba, midway between the umbilicus and sym- 
physis pubis, about two inches long, exposed the tumor and evacu- 
ated several pints of peritoneal effusion. Upon introducing the 
finger to survey the tumor, some slight adhesions were torn through. 
A large trocar was next plunged into one of the presenting cysts ; 
as no fluid flowed out of the canula, it was withwrawn. Attached 
to it was a thick glutinous semifluid, that was so tenacious as to 
admit of being drawn into a string two feet long. It was evident 
that the contents of these sacs could not be thus evacuated. The 
external incision was enlarged until it was about five inches in 
length ; the abdominal walls were pressed closely against the tumor, 
a free incision made into the cyst, and the contents, almost as 
thick and dark as tar, pressed out. The same procedure was re- 
peated upon several sacs until the size of the tumor was considera- 
bly decreased. Upon drawing the partially collapsed tumor for- 
ward, and examining its sides, firm and extensive adhesions were 
discovered in every direction in which the examination was pushed. 
Much of them gave way under the fingers by using considerable 
force ; there were, however, five bands of fibrine, from two to three 
fingers wide; two of them were far around toward the spine, 
which, on account of their firmness, had to be separated by the 
ecraseur. The external wound was again enlarged upward until 
it was about nine inches in length, and the tumor lifted out of the 
abdominal cavity. After passing a double hempen ligature through 
the centre of the pedicle, and securing it by tying each side firmly 
as possible, the chain of the ecraseur was passed through it close 
to the tumor, and above the ligature. Owing to the careful atten- 



OVARIAN TUMORS. 469 

tion of the gentlemen present assisting, very little of the contents 
of the sacs, and probably no blood, found their way into the ab- 
dominal cavity. The external wound was now closed by four pins 
and several silver sutures; the stump was transfixed and retained 
in the wound, with its surface even with the external surface, by 
the pin nearest the pubic extremity of the cut. I should have 
before stated that the great omentum, which lay on the upper part 
of the tumor, was adherent throughout the whole extent of con- 
tact; but these adhesions were so feeble, that they gave way under 
pretty smart force exerted by the fingers for that purpose. 

Very little blood was lost ; and the patient bore this terrible 
operation without any appearance of shock or depression whatever. 
The time occupied in completing the operation and dressing was 
forty-five minutes. A compress wet with water was placed over 
the wound, and secured by a broad flannel binder. The tumor, 
with its contents, weighed thirty pounds. After witnessing the 
extensive adhesions, peculiarity of contents of the tumor, &c, all 
present joined in expressing the opinion that recovery was hardly 
to be thought of as a possibility. 

It will be noticed that, in these two cases, although as great care 
as practicable, on the account of the difficulties of the case, was ob- 
served in avoiding extravasation or effusion in the peritoneal sac, 
no effort by sponging or wiping among the intestines, was made 
to remove any substance that did escape. Such was the case, 
also, in the first operation I ever performed ; and I cannot but ex- 
press the conviction, that the amount of ovarian fluid should be 
very considerable, or acrid in quantity, to justify the rough oper- 
ation of sponging it out. The notes of the case, after the opera- 
tion, were kept and forwarded to me by Dr. J. A. Darling, of 
Eleroy, and I have not altered them, believing them to be a faith- 
ful exhibit of the progress towards a cure. Although somewhat 
lengthy, they show but one interesting circumstance, which is, that 
"our patient" recovered from the effects of the operation without 
a single bad symptom. 

Operation finished Nov. 5th, 12.30 p.m.; pulse feeble, and 120 
per minute ; countenance pale ; nausea and vomiting from effects 
of chloroform; complains of pain in back; took teaspoonful of 
tinct. opii. 2.30 p.m. nausea continues; less pain in back; lies 
on side, disposed to doze ; pulse 120, good volume ; natural color 



470 OVARIAN TUMORS. 

returning to face; respiration 40 per minute. 5 p.m., pulse 112, 
full and soft ; resting well ; respiration 40 per minute ; complains 
of pain in back ; some thirst ; took teaspoonful of tinct. opii, 
which wa,s immediately rejected. 7 p.m., pulse 104; nausea; skin 
cool, soft and natural ; \ gr. morphia, which was immediately re- 
jected ; complains of pain in back ; slight desire to urinate, which 
was relieved by catheter ; has slept some last two hours. 8 p.m., 
pulse 120 ; more urgent nausea, otherwise comfortable ; J gr. mor- 
phia, immediately rejected. 8.45 p.m., J gr. morphia, retained. 
10 p.m., J gr. morphia; some restlessness. Nov. 6th, 2 a.m. \ gr. 
morphia; dozing. 5 P.M., has slept some ; \ gr. morphia ; pulse 
125 ; desire to urinate, relieved by catheter. 8 A.M., pulse 118 ; 
skin cool, soft and natural ; J- gr. morphia ; some nausea. 10 A.M., 
J gr. morphia. 11 A.M., pulse 120 ; inclined to doze. 1 P.M., 
skin moist; breathing good; pulse 120, and soft. 1.15 p.m., re- 
moved bandage, wound looking healthy ; no pain or tenderness ; 
desire to urinate relieved by catheter; pulse 108; 1 gr. opii 
(Tilden's preparation); skin soft and cool; no nourishment taken. 
3 p.m. took a little crust coffee. 3.45 p.m., 1 gr. pil. opii, with 
crust coffee for drink ; inclined to doze. 5 p.m., pulse 120 ; com- 
plains of back, otherwise comfortable. 5.30 p.m., 1 gr. pil. opii; 
complains of occasional shooting pains in abdomen ; pulse 129. 
7.15 p.m., 1 gr. pil. opii, rejected. 7.30 P.M. 1 gr. pil. opii, re- 
tained ; inclined to doze. 8.45 p.m. 1 gr. pil. opii. 10 a.m., re- 
lieved bladder by use of catheter. Nov. 7th, 6.30 a.m., have given 
through the night 1 gr. pil. opii every hour and a quarter ; pa- 
tient has rested well; skin cool ; respiration natural; has no pain 
except in back. 

Nov. 9th. — Our patient, thus far, is exceeding our most san- 
guine hopes. I will continue notes as taken from my book : 

Nov. 7th, 3 p.m., pulse 120 ; tongue somewhat dry and red at 
tip, with thirst; no nausea. 5 P.M., saw patient with Dr. Charl- 
ton; commenced the use of ess. beef, which relishes well; removed 
bandage, wound looking well ; have decreased the opii to 1 gr. 
every four hours ; tongue dry and slightly coated. Nov. 8th, 
3 A.M., patient resting well; tongue more natural; pulse 135. 
7 A.M., pulse 130. 10 A.M., removed bandage, wound looking 
good, with very slight suppuration ; pulse 130 ; commenced the 
use of Tilden's f. ext. veratrum viride, 2 min. every two hours, 



OVARIAN TUMORS. 471 

continuing 1 gr. opii every four hours ; patient cheerful and happy ; 
continues use of beef ess. and crust coffee ; tongue moist. Nov. 
9th, 8 a.m., have continued above treatment through the night ; 
patient rested well ; slight sweating when sleeping ; complains of 
some flatus ; gave 3 gr. carb. soda ; pulse 110, with all other symp- 
toms favorable ; have discontinued use of verat. viride. I would 
here state that I have emptied the bladder regularly. 5 p.m., saw 
patient with Drs. Buckley and Charlton ; removed bandage, wound 
looking healthy ; slight suppuration, healing mostly by first intern 
tion ; pulse 120; tongue moist; skin cool. Nov. 10th, T a.m., 
patient has rested well through the night ; pulse 120 ; tongue 
slightly dry ; has no pain ; have given through the night opii, as 
usual, with verat. viride, every four hours ; patient feels well and 
cheerful ; thinks she has grounds for hope that she will recover ; 
there is but slight distension of abdomen. 

Nov. 12th. — Our patient is prospering finely ; thus far, every- 
thing looks favorable for a recovery. Her pulse this morning is 
84; tongue moist and clean; the only disagreeable symptom is 
wind in the bowels. I moved them yesterday, and shall give ano- 
ther injection this morning. I have continued treatment with opii 
and verat. viride, the same as at first, also anise-seed tea. I am 
giving her all the nourishment she will take in a liquid form. 

Nov. 14th. — Our patient is still doing well, has no fever, nor 
any unpleasant symptoms. I have moved the bowels : I used 
simply an injection of soapsuds with a little turpentine. She 
begins to eat toast and some roast potato, with a good supply of 
beef essence. The wound is looking well ; the superior one-half is 
entirely healed. I have removed one pin and two sutures ; shall 
remove one pin to-day. I have continued treatment same as for- 
merly. 

Nov. 17th. — Our patient is gaining as fast as could be expected. 
The wound is healing gradually, the superior one-half is entirely 
closed, the other is suppurating some. I have removed two of the 
pins and the three sutures, the others I shall allow to remain for 
a few days. I am treating her now with opium and quinine, 1 gr. 
each, every four hours. Her pulse is about 110 per minute, soft ; 
tongue clean and good; skin soft and moist; and all appearances 
favorable. We have strong hopes of a recovery ; I am giving her 
plenty of nourishment. 



472 OVARIAN TUMORS. 

Nov. 19th. — Our patient is gaining as fast as we could hope for; 
she begins to have an appetite for food. I am continuing treat- 
ment with opium and quinine; the wound is healing slowly. I 
have not removed the two lower needles, yet the stump looks well. 
I have moved her bowels with injections about every other day ; 
they have moved once without any medicine whatever. I see noth- 
ing to hinder a favorable termination. 

Nov. 22d. — Dear Sir: Your favor of 19th was duly received. I 
will first answer your questions : 1st. There has not been any hem- 
orrhage whatever from the stump or wound. 2d. There has not 
been distension of the abdomen at any time of any account; she 
only complained one day of flatus. 

She is now getting along as well as could be asked for : has a 
good appetite, feels cheerful, and says she wants to sit up. I have 
removed three of the pins ; I thought it was best to allow the lower 
one to remain for a few days, yet the stump is about on a level 
with the abdomen. I am giving her quinine, with reduced doses 
of opium. 

February 14th. — Both patients have completely recovered from 
the operation, and are in good health. 

Case 3. Mrs. R- , aged 31 years, is the mother of four chil- 
dren, her last being six months old. Immediately after getting up 
from confinement with the youngest, she perceived a tumor in the 
abdomen, which rose above the umbilicus. Since first discovered, 
it had grown quite rapidly, until now, April 10th, 1863, it reaches 
to the ensiform cartilage, fills the abdomen to great distension, 
and causes her much suffering. Upon examination the tumor was 
pronounced ovarian multilocular dropsy. She desired to be re- 
lieved of it in any way that might be deemed best. After consul- 
tation with Prof. N. S. Davis, ovariotomy was determined upon, 
and the 15th instant appointed for the time. The patient was 
prepared by taking tinct. ferri chl. gtt. xxv, three times a day, 
good, full diet, and a soluble condition of the bowels preserved by 
an injection once a day. At the time appointed, the operation 
w T as performed in presence and by the assistance of Drs. Davis, 
Shumway, Bartlett, Cheeney, and four medical students. The 
chloroform, although very carefully administered, caused so great 
prostration and difficulty of breathing that much apprehension was 
felt for her safety. 



OVARIAN TUMORS. 473 

There was one large cyst, from which about ten pounds of thick 
serum was removed by the trocar canula, after a small opening 
through the linea alba had been effected in the usual way ; but the 
other cysts, which were very numerous, were small, and filled with 
such thick fluid that it would not flow through the largest instru- 
ment. The opening was enlarged, in consequence of this fact, to 
about nine inches in length, when the tumor was turned out of its 
bed of intestines and removed from the abdominal cavity. Some 
adhesions, which were not very firm, were overcome by disrup- 
tion, one only requiring the ecraseur; but what embarrassed the 
operator most was the great fragility of the walls of the small 
cysts. These were so tender that the manipulations necessary to 
remove the mass caused rupture of some of them, and the conse- 
quent effusion of their contents into the peritoneal cavity in spite 
of all care to avoid it. The pedicle was thick and very vascular, 
hence it was thought best to tie it with a double ligature, as in the 
two last cases. The wound was dressed with silver pins as usual. 
The operation, which occupied about forty minutes, was completed 
at 3J- o'clock p.m. The temperature of the room during the oper- 
ation was about seventy degrees, and the atmosphere rendered 
moist by evaporation from boiling water. The shock of the op- 
eration, or the effect of the chloroform, left her quite depressed. 
The pulse was low and weak ; the surface pale and unnaturally 
cool. Dr. Bartlett remained with her. At 4 o'clock and after, 
he gave her a teaspoonful of brandy in some water every half 
hour. He gave her also at that hour morph. sul., gr. Jth, as she 
commenced complaining of pain in the location of the wound. The 
morphia was administered every half hour also until the pain was 
relieved, which occurred at 5.30 p.m. The brandy was continued 
all night every half hour, and the morphia every three hours in 
same dose as before mentioned. Her extremities, which were too 
cool, were wrapped in warm, dry flannel. At 1 a.m., 16th, the 
urine was drawn through the catheter. 8 o'clock a.m., pulse 85 ; 
surface natural, tongue moist and clean, spirits good, and the pa- 
tient in every way comfortable, except occasional nausea. 

The bladder was again evacuated, the brandy discontinued, and 
one tablespoonful of beef essence every two hours. At 1.45 p.m., 
pulse same in number, but stronger and fuller ; some serum oozing 
from the wound ; the skin moist, but a little too warm ; some pain 



474 OVARIAN TUMORS. 

in the back and wound ; tongue somewhat red on the tip and edges, 
and coated over the central part white ; some thirst, which has 
never been urgent. Take ice and small quantity of ice-water, con- 
tinue beef essence, and take Jth grain sul. morph. often as neces- 
sary for pain. 

8.15 p.m., patient restless; countenance anxious; pulse 120, 
firm, but not full ; skin moist, but too warm ; pain in the back ; 
abdomen somewhat distended. The patient complains of urgent 
thirst, and expresses doubt about recovery. Morphia sul., gr. J 
every four hours ; use the catheter every eight hours ; give ice ad 
libitum; beef essence as before. 

8 a.m. 17th, tongue moist, red at edges and tip, white fur in 
centre ; pulse 120 ; respiration 32 per minute ; still thirsty and 
restless, with pain, requiring the morphia as above directed. The 
abdomen is more distended and tympanitic. The wound continues 
to discharge serum, which is becoming somewhat foetid. Continue 
treatment, with the addition of brandy, as much as the patient can 
be induced to take with ice-water. 

11.30 p.m., tongue dry ; pulse 140 ; respiration 32 per minute ; 
cheeks and extremities cool ; body hot and moist, particularly the 
abdomen ; pain in back more considerable ; abdomen greatly dis- 
tended ; the patient complains of great weakness, approaching to 
syncope ; treatment continued. I forgot to mention that soon as 
the abdomen began to increase in size, it was covered with linseed- 
meal poultices, which were kept moist and warm up to the time of 
her death. The patient continued to sink ; the abdomen to in- 
crease in size until it was enormously distended. She expired on 
the 18th, at 5 o'clock p.m. We could not procure a post-mortem 
examination, but I think there is no doubt that peritoneal inflam- 
mation was the cause of death. 



CHAPTEE XXIX. 

DISEASES OE THE MAMMAE. 

Inflammation attacks the mammae of infants, children, and 
youth of both sexes, and of women childless or senile; but in the 
present article, I desire to confine myself to the disease as mani- 
fested in the pregnant, puerperal, and lactiferous conditions of 
females, the conditions in which the mammae are functionally ac- 
tive, or preparing for the discharge of their duty. 

Inflammation may invade the tissue in and about the breasts, as 

1st. The involucra. 

(a) The skin and integuments, areolar glands, follicles, &c. 

(b) The suspensory fascia covering and containing the whole 
breast, and its intra- and sub-glandular processes and laminae. 

2dly. The lymphatic glands, superficial and deepseated ; 

Or the structures entering more intimately and essentially into 
the formation of these, as 

3dly. The nipple and milk-ducts contained within it, constitut- 
ing the eliminatory apparatus. 

4thly. The sub-areolar expansion of the milk-tubes, called by 
Sir Astley Cooper, milk-reservoirs. 

These reservoirs actually occupy nearly the whole front part of 
the breast, immediately beneath the integuments and fascia, and 
lie above the gland in all parts of the breast except the margin, 
where the hard substance of the gland may be felt. 

5thly. The lacteal gland and cellular tissue, which pervades 
every part of it, and which is the medium of connection between 
the lobes, lobules, tubes, vessels, and nerves of its substance. 

Although very few cases of mammary inflammation occur in 
which the disease is confined to one structure, and many in which 
several are simultaneously invaded, yet I think an intelligent ana- 
tomical division will conduce to clearer views on the subject. I. 
shall, therefore, base what I have to write about mammary inflam- 
mation upon the foregoing consideration with respect to its seat. 



476 ACUTE INFLAMMATION OF THE BREAST. 

It might be supposed that the integuments, or involucra of the 
breast, were as liable to disease at one time as at another; and 
hence, at the time when the various processes connected with gener- 
ation are passing, should enjoy their usual exemption from disease, 
but observation proves the contrary. 

It may not be expected that I shall dwell at any length upon 
the eruptive or specific diseases which may attack the breast, for 
they may occur at any time ; nor erysipelatous and rheumatic af- 
fections,' which more frequently than is generally believed attack 
the structures. Rheumatism of the fascia of the breasts I think 
I have witnessed repeatedly ; it is manifested by the usual charac- 
teristics as in other parts. Almost the only sort of inflammation 
to which the integuments are subject, that can particularly inter- 
est us now, is phlegmonous. Of course, the real seat of the in- 
flammation, or, at least, its beginning, is in the areolar tissue 
beneath the skin. Generally, it is circumscribed and single in 
locality ; often there are several simultaneous or successive foci ; 
less frequently it is quite diffuse, involving a large surface, caus- 
ing great deformity and damage to the organ, and attended with 
serious constitutional disturbance. 

Phlegmonous subcutaneous inflammation in the breast is at- 
tended with the symptoms which usually accompany it elsewhere, 
— pain, heat, redness, swelling, hardness, tenderness in the early 
stages, varying in intensity with the extent and acuteness of the 
affection. We may generally diagnosticate this from inflamma- 
tion in other tissues of the breast by isolation. There is usually 
no trouble in the secreting, eliminating, or containing apparatus 
of the breast. The functions of the whole organ are properly 
discharged. The inflammation is one generally of inconvenience 
instead of damage. It is superficial, and we may ordinarily get 
below it by manipulation, so that we can assure ourselves it is out- 
side the mamma. Most frequently the areola is the seat of this 
kind of inflammation. There can be no question, however, but 
that the deep cellular tissue is as often the subject of inflammation 
as any other of the de'ep structures ; and, indeed, some good pa- 
thologists think it is the seat of disease, when we suppose the 
gland to be the part affected. However this may be, inflamma- 
tion of any of the deep tissues generally brings this into the mor- 
bid mass. Inflammation of the superficial areolar tissues occa- 



INFLAMMATION OF THE NIPPLE. 477 

sionally involves the reservoirs or glands by contiguity. I have 
but little doubt that the diffuse intromammary suppuration which 
we see sometimes take place, and produce such prodigious quanti- 
ties of pus, often melts down the connective areolar tissue distrib- 
uted between the lobes, lobules, and tubes of the organ, without 
always at least attacking the more essential structures. I cannot 
hope, however, nor do I design attempting, to distinguish between 
deepseated cellular and glandular inflammation. The distinction, 
if made, so far as I can see, would not lead to any practical re- 
sult. Chronic superficial cellular inflammation does not often 
occur, except as it becomes chronic by a long-continued succession 
of small abscesses. It is possible, also, that the chronic sequela 
of cellular inflammation, as exhibited in hard tumors, may be of 
this character in some instances. When this is the case, we should 
expect to find the hardness not so defined, but shaded off into other 
parts, somewhat regular in outline, and not sharp, irregular, and 
lobulated. 

Inflammation of the Nipple. — This may be accompanied with 
abrasions, fissures, or ulceration. Abrasion is most frequently 
seen on the apex of the nipple, and is the condition in which the 
delicate epidermis is removed by action of the child's organs in 
sucking, leaving the dermis naked, bleeding, and raw. It may, 
however, be observed on any part of the nipple. Not unfre- 
quently, these abrasions are increased in depth by ulceration, until 
a greater or less portion of the nipple may be destroyed. Cracks 
or fissures, likewise, often affect the nipple. These cracks are lo- 
cated either on the top, sides, or at the base of the organ. The 
apex of the organ, sometimes, is so deeply fissured, as to lay it 
open to the bottom of this projection, and leave it split in halves ; 
but usually it is much less extensive, and it simply lays open the 
top of the nipple to the depth of the skin. The worst fissures that 
occur on the nipple, however, generally more or less completely 
encircle the base of the organ. To such an extent are fissures 
of the base carried by ulceration, sometimes, as completely to 
amputate this little projection. Abrasions and fissures lead al- 
most invariably to ulceration ; and we may consider these as the 
first stage, so to speak, of ulceration. 

This ulceration, of course, resulting as it usually does from 



478 DISEASES OF THE MAMM^ : 

abrasions and fissures, occupies the place which I have assigned 
to them. 

The symptoms which accompany these three conditions of the 
skin of the nipple do not differ each from the other, and without 
inspection we would not probably be able to distinguish between 
them. There is great pain upon handling the part, or when the 
child sucks ; indeed, it is so very severe as to render it entirely 
intolerable to the patient, and cause her to resist every request, or 
even command, to nurse the child. When the child is put to the 
breast, in addition to the pain, they bleed so as to disorder the 
milk, and sometimes sicken the child, and cause it to vomit up the 
contents of the stomach. The extent to which ulceration may 
proceed, under the irritating influence of nursing, is sometimes 
very great. 

I remember an instance in a patient affected with stomatitis 
materna, where the nipple was completely destroyed, and the place 
where the nipple had been, excavated below the surface before ul- 
ceration was arrested. Every experienced physician must have 
seen cases where the nipple was cleft, cut off, or very badly muti- 
lated. Ulceration has its origin in many cases, also, in small 
phlegmonous inflammations of the cellular tissue of the nipple. It 
not unfrequently happens that small pimples arise, suppurate, 
burst, and, on account of the constant irritation of nursing, re- 
main open, and pass into a state of ulceration which is often very 
obstinate. 

Small ulcerations occasionally occur in the same way on the 
areola, but not with anything like the frequency of those of the 
nipple. Neither are they so painful as when situated on the nip- 
ple. The parts being less firm, the swelling does not so greatly 
press upon and distress the surrounding parts. Such diseases 
of the areola get well much easier than those upon the nipple, 
because they are less disturbed in that place by the child when 
sucking. 

Inflammation of the Lymphatic Glands of the Mamma. — It is 
important, in a diagnostic point of view, to bear in mind the fre- 
quency of inflammation of these glands. As in other parts of the 
body, so in the breasts, they inflame in consequence of the pas- 
sage of acrid or unhealthy lymph through them derived from in- 
flamed tissues. Ulcerations and abrasions of the nipple and areola 



INFLAMMATION OF THE LYMPHATIC GLANDS. 479 

are frequently followed or accompanied by the inflammation of 
these bodies. No doubt enlargement by deposit, leading to chronic 
inflammation, may also sometimes occur independent of inflamma- 
tion. The indolent tumors over the gland and near its margin, on 
the inner, outer, and upper circumferences, are in frequent in- 
stances chronically inflamed lymphatic glands. 

The symptoms of inflammation of these glands do not differ in 
the acute form from those attendant upon superficial phlegmon. 
All the distinguishing circumstances of inflammation are expe- 
rienced. They are, probably, more circumscribed than ordinary ; 
the margin is more defined, and does not shade off into the healthy 
tissues, but appears, as it were, encysted. This is the case, how- 
ever, only at first, as the inflammation often spreads to surround- 
ing tissues, when the difference cannot be clearly made out. 

As the inflammation subsides, hardness is left for a much longer 
time than in phlegmon of the integuments. The acute symptoms 
merge into chronic, and hardness, tenderness, and, in many in- 
stances, discoloration, last a considerable time. Suppuration does 
not occur so quickly as in phlegmon, and resolution much oftener. 
To make out a diagnosis, we should remember the more common 
seat of the two. They are ordinarily both (phlegmon and inflam- 
mation of the lymphatic glands) small in size, usually not larger 
than an English walnut ; but phlegmon occurs about the areola, 
while the other is usually located over the gland, and near its 
margin. The phlegmon may occur in any direction from the 
nipple with reference to circumference, but lymphatic inflammation 
is situated at the inner- or outer upper edge of the mamma. In 
scrofulous or broken-down patients a chronic condition of inflam- 
mation is likely to take possession of these glands, or they may 
be filled with albuminous accretions and undergo indolent changes, 
which might lead the inexperienced to fear malignant disease. I 
have a patient who has a deep lymphatic tumor in the breast on 
the axillary margin, who assures me it has been in the same con- 
dition for six years. This tumor is hard, round, regular, a little 
flattish, freely movable, and resembles lymphatic enlargements at 
the clavicle and groin in the same patient. 

They may be usually distinguished from malignant tumors when 
indolent and not tender from inflammation (for malignant tumors 
are not sensitive in the beginning), by being more rotundly irreg- 



480 DISEASES OF THE MAMMJ1 : 

ular, without the sharp outline generally characterizing malig- 
nant disease. If they are livid, they are also tender ; if they in- 
volve the skin, they are tender to the touch, and the skin is in- 
flamed. Neither of these conditions obtains in malignant cases. 
The malignant tumor may be livid and almost insensible. It may 
involve the skin, attach itself to it, and not inflame it. 

The lymphatic tumor is hard alike all over ; if softer in one 
part, that part is the centre. The malignant is harder in the 
centre until nearly ready to ulcerate. When the lymphatic tumor 
has ulcerated, the cavity is regular, and red or pale about the 
edges, and secretes pus. The malignant ulcer is ragged and ex- 
ceedingly irregular ; in fact, sharp irregularities of edge and 
cavity mark peculiarly malignant ulcerations ; the edges are livid, 
not red nor pale, and ichor instead of pus is produced. In the 
ulcerated lymphatic there is no smell ordinarily, certainly none 
but the smell which may arise from uncleanliness. A malignant 
ulcer will smell in spite of us, and the smell is peculiar, and when 
once noticed will be recognized without difficulty again. Lym- 
phatic glands may be inflamed singly or in numbers, several being 
the subjects of inflammation at the same time, or only one. As 
I have before intimated, the disease may be chronic or acute — in- 
dolent or active. 

Milk Abscess. — Passing to the deeper structures of the breast, 
we encounter inflammation of the containing portion of the mam- 
ma, the expanded milk-tubes, the milk-reservoirs. There are 
from fifteen to twenty-five of these expanded tubes, holding from 
one to two drachms each in the natural condition. They are 
separate and distinct, each tube representing a lobe of the gland. 
One or more of these may inflame, ulcerate, and discharge the 
milk, mixed with a greater or less quantity of pus. Inflammation, 
followed by ulceration and discharge of pus and milk of these res- 
ervoirs, is alone what should be called milk abscess. Abscesses 
from this part of the breast do not occur singly as a general thing. 
Several are going on at the same time, one arriving at the ulcer- 
ated stage after another, so that we have a succession, each ab- 
scess involving one tube, and sometimes, but not often, more. 
They are seated under the anterior surface of the breast, mostly 
within an inch of the areola, and sometimes under it. In some 
persons the reservoirs are large, extend a considerable distance in 



MILK ABSCESS. 481 

every direction from the areola, and overlay the gland almost to 
the margin of the mamma. Milk abscess need not necessarily be 
near the central portion of the organ, although they generally are 
not far from the areola. They usually proceed somewhat slowly, 
taking longer to arrive at the suppurative stage than in superficial 
phlegmon. Swelling and tenderness are felt near the areola; it 
increases steadily until an apex is observed in the tumor ; the in- 
teguments are thinned, fluctuation is observed, and rupture fol- 
lows. This process requires a very different length of time under 
different circumstances. If the milk is secreted rapidly, the tube 
is distended faster ; if secretion is scanty, the advance is slower. 
The inflammation depends upon distension of the reservoirs by 
milk which cannot find its way out of the milk-tubes. Retention 
of milk is caused by several different circumstances, which I shall 
have occasion to mention after awhile. I wish now to be under- 
stood as saying that it is the essential cause of the inflammation 
in this form of disease. The milk is secreted, but not eliminated 
from the reservoir affected. It acts as an irritant by its great 
accumulation, until inflammation is the result. The secreting ca- 
pacity of the organ is not necessarily disturbed, and the excretion 
of the milk may be ready and easy through all of the tubes whose 
reservoirs are not affected, and we may think it is being evacuated 
entirely while it is retained in one or more reservoirs by the stop- 
page of the nipple-tubes. When evacuation, either spontaneously 
or by the lancet, is effected, pus and milk flow in moderate quan- 
tities at first. The pus gradually diminishes, the milk becomes 
more pure, until a milk-fistula occurs, which lasts a greater or less 
time. Should the eliminative tube become open, and allow the 
milk to flow from the affected reservoir through the nipple, the 
adventitious opening may entirely heal, and the integrity of the 
part be restored ; but, as is most frequently the case, the fistula 
remains open until the breast ceases to secrete, all the milk pro- 
duced by the lobe whence the reservoir is supplied flowing out at 
the place. 

Sometimes, again, after breaking and discharging, it suddenly 
heals up, distension recurs, and the process of ulceration and dis- 
charge is repeated. ' 

The sympathetic symptoms are not generally so great as in 
some other varieties of mammary inflammations. Fever does not 

31 



482 DISEASES OF THE MAMM^ : 

run so high, aching of the head, limbs, &c, do not distress the 
patient so much. Yet they sometimes are quite considerable, and 
require alleviation by appropriate remedies. The damage done to 
the breast by inflammation attacking these parts is not so great as 
results from glandular inflammation generally, though I have 
known instances in which nearly all the reservoirs were destroyed, 
and the breast henceforth remained useless. One of the worst 
features of the case is derived from the persistent repetition of 
abscesses, wearing out the patience of the medical attendant and 
the powers of endurance of the patient. It is always complicated 
by disease or deficiency of the nipple. Besides this ulceration or 
phlegmonous inflammation of the milk-reservoirs, there is another 
form, in which blood and pus are discharged through the nipple- 
tubes, the passage from them being free. Yery few experienced 
physicians but have seen this discharge of pus, blood, and mucus 
from the milk-tubes, with tenderness and some tumefaction under 
the areola. It is generally considered to be an abscess discharg- 
ing in this way, but it is ordinary inflammation of the lining mem- 
brane of the milk-reservoirs discharging its products through the 
nipple. Abscesses occurring as the effect of over-distension of 
the reservoirs do not give origin to those deep, ungovernable 
sinuses that sometimes trouble us in glandular inflammation ; and 
while there is often milk-fistula following them, these close as soon 
as the secretion ceases, and we have no further trouble. 

Several times in my life I have met with these abscesses during 
pregnancy, in which the accumulation of pus and milk was very 
great, so that when they are opened, many ounces of pus and im- 
perfectly formed milk were discharged. Several months since I 
was called in consultation in a case, in which the disease had be- 
gun three months before labor ; and when I saw the patient, the 
child was two months old, and large collections of pus and milk 
existed, pent up in the reservoirs, with impermeable tubes in both 
breasts ; and while some of the reservoirs contained and their tubes 
discharged milk upon nursing, half of them were the subjects of 
purulent inflammation. Generally, the inflammation which causes 
the evacuation of the milk and pus checks the secretion of milk, 
and the patient recovers before the time for labor. This is for- 
tunate when it occurs. According to my observation, this is the 



GLANDULAR ABSCESS. 483 

most common of mammary abscesses ; indeed, I think, by a large 
majority. 

Glandular Abscess of the Mammce. — This is the most grave of 
acute inflammations of the breasts occurring during lactation. I 
am not aware of ever having seen an instance of mastitis proper, 
unless caused by violence, in any other than nursing women. 
When the inflammation takes place early in nursing, it usually 
comes on about the third or fourth clay. Mastitis cannot, in the 
first few hours, be distinguished from the intense congestion which 
occurs at the time the secretion of the milk is first produced. In 
either case the woman is seized with a severe chill, in which it is 
not uncommon for her to shake and chatter as in violent ague. 
In the course of an hour or sometimes longer, sometimes in a few 
minutes, the chill gives place to a violent reaction ; a high fever, 
pain in the head, limbs, back, and often abdomen, annoy the pa- 
tient. All the phenomena of severe inflammatory fever occur. 
When the congestion subsides into a copious effusion of milk in 
the cells of the gland, the fever declines, a copious perspiration 
appears over the whole surface, and comfort succeeds great uneasi- 
ness and sometimes alarm. 

When, however, the gland is not completely relieved by secre- 
tion, this transition from a state of febrile reaction is imperfect, 
and the patient is left with more or less of the symptoms of fever. 

Simultaneous with these general symptoms there is pain, tume- 
faction, tension, heat, and tenderness of the mamma. If the se- 
cretion is established, the breast, as the sweating stage advances, 
becomes soft, cool, and less sensitive, until it is entirely comforta- 
ble. On the other hand, if inflammation is to succeed congestion, 
some part of the organ is left in a hard, tender condition. A hard 
lump, of greater or less size, continues to occupy some deep por- 
tion of the breast. Tenderness, tumefaction, heat, and redness 
increase, until inflammation is permanently fixed. Without early, 
energetic, and appropriate treatment, the woman will lose part of 
the mammary gland by destructive suppuration. 

In the beginning of glandular inflammation, if the part be at- 
tentively examined, the shape and position of the lump will enable 
us to determine the seat. It will be either deep in the central por- 
tion of the breast, or in the marginal region. The tumid part is 
irregularly lobular; depressions and elevations may be observed, 



484 DISEASES OF THE MAMMJ1 : 

nodular, not sharp ridges. Very soon after the inflammation be- 
gins, particularly should it be advancing, this nodular feel is 
merged in diffuse hardness of the surrounding parts, until the 
whole tumor may become smooth and irregularly defined. In- 
flammation, hardness, and tenderness, increase for a few days, 
when the centre becomes slightly soft at first, growing more so, 
until distinct fluctuation is perceived. 

At this time we find a soft fluctuating locality completely mar- 
gined by hardness all round. This, then, will be the feeling of a 
mammary abscess, whether acute or chronic. Glandular abscess 
differs from milk abscess, by being at first much deeper, having a 
covering of integuments, &c, half an inch or more in thickness, 
while milk abscess, though quite hard, seems to be immediately 
beneath the integuments. When fluctuation is first perceptible in 
milk abscess, it is shallow ; in mastitis it is deep, and makes its 
way slowly to the surface. When pus arrives at the surface, and 
ulcerates through, or is evacuated by the lancet, its flow is much 
more difficult, and the evacuation less complete ; relief is not so 
sudden and perfect. Extensive destruction takes place, both in 
the internal portions of the organ and in the integuments ; and so 
tortuous and irregular are the tracks of transit, in some instances, 
toward the skin, and the pus finds its way out with so much diffi- 
culty, that the sinuses are sometimes extremely difficult to heal. 
This state of things may last for many weeks and even months. 
We not unfrequently find cases in which these sinuses are numer- 
ous, tortuous, and lengthy, so as almost to riddle the internal 
structure of the organ, and discharge large quantities of pus, thus 
draining the system of the woman, inducing hectic, exhaustion, 
and, in extreme cases, death. 

Often, instead of beginning at the time of puerperal congestion 
of the mamma, mastitis shows itself late in lactation. When oc- 
curring at such times, it may spring up suddenly, inducing all the 
general phenomena above described, in a greater or less degree of 
intensity ; or it may be slowly established, and not bring the sys- 
tem into so decided sympathy and perturbation. Yet in the latter 
case, as the inflammation becomes more completely established, 
fever is pretty certain to be manifested, its intensity being greater 
or less, according to the extent of tissue involved, the rapidity with 
which it advances, and the susceptibility of the patient. 



CAUSES OF MAMMARY INFLAMMATION". 485 

The first thing noticed, perhaps, is what the woman would call 
cake in the breast, of moderate, yet decided tenderness. This 
consists in inflammation in one or more lobes of the mammary 
glands. It gets worse; the swelling becomes greater, the tender- 
ness more considerable; instead of the well-defined nodular tumor, 
the swelling is more diffuse ; other parts are involved, redness in 
the skin is observed, sympathetic fever sets in, and then it passes 
through the different grades above mentioned in the acute variety, 
with less intensity. 

In glandular inflammation, milk is suppressed more or less per- 
fectly, owing to the amount of tissue involved. 

Causes of Mammary Inflammation. — As I have intimated, the 
pregnant, puerperal, and suckling conditions of women may be 
regarded as predispositions to mammary abscess. Women are 
much more liable to them when in these conditions than at any 
other time. Hence it would not be improper to say, that these 
states of the system are predisposing causes of mastitis and its 
associate inflammation. The physiological congestion preceding 
and accompanying the commencement of lactation very frequently 
is carried too far, and merges into pathological congestion, and 
this again into inflammation. When inflammation arises from this 
cause, it will almost invariably be mastitis, or glandular inflamma- 
tion. This sort of congestion may occur later, but usually it is in 
the puerperal condition. Another sort of congestion, which often 
runs into inflammation of the glands, is brought about by sexual 
intercourse in very excitable nursing women. I think I have 
known several instances of this kind. Other passions, as anger, 
may be succeeded by like results. Vascular excitement from stim- 
ulants will endanger the breasts in puerperal women, also. Ex- 
ternal causes may give origin to similar sorts of inflammation, as 
bruises* from blows, tight lacing, stays of whalebone, &c. These 
last are productive of a good many cases. Not unfrequently our 
patient gets up well from the effects of labor, and the first time 
she dresses to go out, pinches her excitable gland with lace-strings, 
or punches it with the end of a piece of whalebone during the 
whole of her round of fashionable calls, and comes home with the 
breast excited to inflammation. Cold, acting partially upon the 
person, as the feet, the breasts themselves, or even upon the gen- 
eral surface, repels the blood to the already blood-loaded gland, 



486 DISEASES OF THE MAMM^ : 

producing congestion as the first step of inflammation. Other ex- 
ternal causes operate upon the nipple and surface of the breast, 
irritate the skin, or destroy its integrity, &c. The child often 
sucks off the epidermis, and by thus abrading the nipple, ulcera- 
tion is brought about. 

Allowing milk or saliva to remain in contact with the delicate 
skin of the nipple, or areola, long enough to undergo decomposi- 
tion, too often is the cause of ulceration, more especially when the 
saliva of the child is rendered poisonous by the existence of aph- 
thous incrustation upon the tongue, gums, and roof of the mouth. 
The cracks so often found upon the nipples, I think, are almost 
invariably produced by the habit of allowing the fluids deposited 
upon the delicate skin to slowly evaporate, and thus carry off, or 
otherwise neutralize, the sebaceous unction of these parts, which 
is intended to keep the cuticle pliant and soft. 

There is a class of causes which I am disposed to call patholog- 
ical, very prolific of grave mammary diseases. One affection may 
act in producing another. Thus, ulceration of the nipple prevents 
proper efforts to draw the milk from the reservoirs ; they become 
distended to a degree that causes inflammation ;. or the ulceration 
on the top of the nipple, by the swelling it causes in the inter- 
tubular issue, lessens the diameter of the tubes, or entirely closes 
up their mouths, so that milk cannot find its way out, or be drawn ; 
accumulation results, and inflammation follows. Cracks, of course, 
will do the same ; or, again, the inflammation originating on the 
nipple, may creep down the lining membrane of the milk-tubes 
into the reservoirs, or even farther, through the ramification of 
the radicles of these ducts, to the substance of the gland itself. 
In either of these localities, suppurative inflammation may arise, 
and proceed through all its most aggravated forms. Contiguity 
of inflamed parts may awaken inflammation in other parts. In- 
tegumentary inflammation may extend to the reservoirs or glands, 
by spreading from one tissue to another. There can be but little 
doubt that acute, and, in most cases, chronic inflammation of the 
lymphatic glands, is generally secondary to inflammation and ul- 
ceration of the nipple and areola. It would probably be too 
strong an assertion to make, to say that inflammation of the lym- 
phatic glands always has its origin in this way ; for in cases of 
strong predisposition to this disease — and there are numerous in- 



CAUSES OF MAMMARY INFLAMMATION. 



487 



stances of that kind — it would probably arise without much cause 
of excitement. Certainly, I cannot be mistaken in supposing that 
I have seen several such cases. 

Anatomical causes of inflammation of the breast exist to a great 
extent. They are sometimes congenital and hereditary ; but I 
think, for the most part, brought about by improper dressing. 
The flat, undeveloped, or retarded nipple, is one form of anatomi- 
cal peculiarity which prevents the perfect performance of suck- 
ling, as is represented in Fig. 27. The retention of milk will lead 
to milk abscess. Nursiilg is often impracticable in this breast. 
Fig. 28 represents a breast with a very broad but extremely short 
nipple, entirely too large for a child's mouth, and so short as to 



Fie. 21 




Interior View. 



add to the difficulty of prehension. Fig. 29 represents a breast 
with scarcely a trace of the peculiar, warty, tissue-like nipple, sim- 
ply pouched slightly where the nipple ought to be ; or, a very 
small nipple, where the milk-tubes seem to be bound in such a 
contracted bundle as not to allow free egress to the milk, is rep- 
resented in Fig. 30. These four specimens of nipples, which we 
often meet with, are almost impracticable. The first and third 
quite so ; and the second and fourth so difficult that we are gen- 
erally driven to the necessity of abandoning it after the best di- 



488 



DISEASES OF THE MAMflLffi: 



rected efforts to make the breast available. The danger to breasts 
furnished with such nipples is, that the milk will not be properly 
evacuated, and that milk abscess will result. In Fig. 31 we have 



Fig. 28. 



Fig. 29. 



Fig. 30. 




a nipple large enough to be easily apprehended and drawn by the 
child, but it is too constricted at the base. The milk-tubes, upon 
entering it, turn too acute an angle. A little swelling of the sub- 
areolar tissue from retention of the milk will stop them entirely 
up, so -that the milk will not pass out. In order the better to illus- 

Fig. 31. 




Interior View. 



trate what I mean, I add a sectional view of this kind of breast 
and nipple. At a, the milk-reservoirs may be seen contracting at 
the nipple, forming the milk-tubes, which turn abruptly upward 



TREATMENT OF MAMMARY INFLAMMATION. 



489 



and even a little outward. This will be made still plainer by 
giving what I call a model breast and nipple, Fig. 32. It speaks 
for itself. The nipple is slightly conical, the base being larger than 
the apex. I add also a sectional view of this breast. As will be 
seen, the milk-tubes are free from pressure everywhere. Their 
entrance into the nipple is by a slight curve instead of an angular 
turn. The milk will flow spontaneously from this kind of breast, 
and there can be no accumulation in the reservoirs. In nipples 
represented by Fig. 31, one danger is that milk, saliva, and mucus 
will collect in the groove around the base, decompose, and thus 
induce mammillitis with its attendants and consequences. This 
could not well occur in the case of Fig. 32. There is no lodging- 
place ; the nipple would be wiped clean of all these accumulations 
by the mouth, and return of the breast inside the clothing of the 
mother, ^he shape of the mamma may predispose it to disease, 
but not in so striking a manner. The more conical a breast the 



Fier. 32. 




l#!fl|i!IIIIPP^^ 
Interior View. 



better. A flat sessile mamma is more likely to inflame. Although 
the above-mentioned varieties of nipples are not the only ones pre- 
disposing to mammary abscess, yet by drawing the attention of 



490 DISEASES OF THE MAMMJ1: 

the profession to the subject thus distinctly, it is believed there 
will be no difficulty in recognizing adverse anatomical peculiarities 
whenever they do occur. 

It might be appropriate to examine into the cause of these ana- 
tomical differences in the shape of this interesting organ, but the 
length of the subject will not allow me to indulge in this direction. 
Like all other formations, the nipple would doubtless differ under 
the same circumstances in different persons naturally, but I think 
there is no doubt much of the deficiency is produced by tight 
lacing, and the pressure made directly upon the nipple for a series 
of years during its development. 

More regard to dressing, as well as education, is bestowed upon 
fitting the young lady to get married, than to perform her func- 
tions properly after getting married. 

Treatment. — I can better give my views of the treatment of the 
affections above described, by observing the same general division 
with reference to the application of the processes of cure. Inflam- 
mation of the nipple will come up in this order of the arrangement 
for consideration first. Our means of cure for mammillitis should 
be arranged under three different heads, as follows : prophylactic, 
palliative, and curative. The first have for their object the prepa- 
ration of the nipple for the trials through which it has to pass at 
the time of nursing. As has been seen, the causes operating upon 
it produce abrasions or chaps, and their action is greatly facili- 
tated by the natural and acquired tenderness of the structure, par- 
ticularly the epidermis and skin. The prophylactic means to be 
used are such as harden these. As elsewhere, so in the nipple, the 
skin becomes tough, and the epidermic scales abundant and adhe- 
rent, upon exposure to air and friction. The contrary condition 
will obtain — tenderness, &c, — from pressure and covering with im- 
permeable or great thickness of dress. In this condition it is pro- 
tected by extraneous covering, and hence does not furnish its own 
proper defence. The epidermis will be thin and light, and the 
skin tender. The nipple, therefore, should be covered lightly 
during pregnancy and nursing. The thinner and more permeable 
the covering the better. It should be of such a character as freely 
to admit the air. At the same time it should be subjected pretty 
constantly to moderately rough friction. 

An excellent dressing for the nipple for the last two months is 



TREATMENT OF MAMMILLITIS. 491 

a rough, coarse sponge, so cut as to cover the areola, and surround 
and cover loosely, but touch, every part of the nipple. Over this 
there should be but one thin texture of raiment, so as to allow of 
the evaporation of fluids as fast as secreted, and the free admission 
of atmospheric air. In cold weather, when going out, the breast, 
of course, would be covered by all the clothing that is used for 
the protection of other portions of the person. It is a great mis- 
take to cover these important organs, — important on account of 
their usefulness instead of their beauty, — so thickly as they usually 
are ; they bear exposure with great impunity. When we wish to 
harden the nipples, we should bear in mind the circumstances which 
harden our hands, and make use of them; we should equally avoid 
the circumstances that soften our hands. When a lady wishes to 
soften and whiten her hands, she wears kid gloves, and does not 
allow them to touch hard substances. In a like manner she may 
soften her nipples if she wishes to do so. To occasionally moisten 
them with water, and to allow it to evaporate slowly on exposure 
to air is a good expedient to harden them. Friction, with a dry 
towel or the fingers, will assist in this process. It is a matter of 
great question whether the various washes used to harden the nip- 
ples are not injurious instead of beneficial. They generally exert 
a chemical as well as physiological effect, while this last is all that 
is desired. During lactation the same exposure to air and light- 
ness of covering should be observed, and, after nursing, the nip- 
ple should be wiped clean and dry before being returned under the 
clothing. This is a rule that should never be neglected. Those 
who have observed the effect of allowing the udder of a cow to dry 
spontaneously after the calf is taken from her, will understand the 
importance of attending to this matter. It will be all the better 
to use a little glycerine or very fine olive oil after they are dried 
each time, particularly if we have reason to apprehend danger of 
chaps or cracks. Such prophylactic measures will very generally 
enable us to avoid the occurrence of distressing chaps or cracks. 
When, however, the nipple becomes inflamed, these are not suffi- 
cient to satisfy the demands of the case, and we must resort to 
palliative and curative measures ; and first of the palliative. As 
the nipple must be used in order to preserve the functions of the 
breast, and as every time the child sucks the healing processes 
that have begun must be more or less interrupted, it becomes im- 



492 DISEASES OF THE MAMM.dE : 

portant to procure such means as will preserve the breast from the 
effect of these interruptions as much as possible. The chaps and 
abrasions that occur and give rise to inflammation and ulceration, 
may be located anywhere upon the nipple, at its summit, sides, or 
base ; and when the child nurses, the tongue and labia embrace it 
so closely that none of these places escape. The artificial means 
used to palliate the effect of sucking intervene between the mouth 
of the child and the nipple, and should be selected with special 
reference to each case. The shield of ivory or britannia answers 
very well when properly managed. They are made in the form of 
a conical hat, having a rim, a crown cavity, with a draught-tube 
rising out of the top for the milk to pass through. Now, having 
in mind that these three parts must vary in length and size for 
different-shaped nipples, and cases in which the locality of the 
abrasions or chaps are different, we will have no trouble in making 
a profitable selection. The rim should be large enough to cover 
the areola, the crown or nipple-cavity large ^enough to pass over 
the nipple, merely touching it on the sides. These things should 
be observed in all cases. The depth of the nipple-cavity is a mat- 
ter of the greatest importance. If the abrasions or chaps are on 
the summit of the nipple, it should be so deep that when drawn 
the top of the organ will not touch, or else it will cause pain. 
There should be no pressure on the top. But if the cracks or 
abrasions are on the sides, or at the base of the nipple, then the 
cavity of the shield must be shallow, so that the top of the nipple 
touches its bottom in such a manner as to prevent stretching the 
organ, and bring the pressure on the top altogether. In this latter 
case, the bottom of the cavity should be as smooth as possible, 
and correspond in shape to the summit of the nipple, in order to 
prevent unequal pressure. The shield, of proper shape, size, &c, 
will afford great relief to the patient, and prevent very much the 
disturbance to the healing nipple. It is not a matter of indiffer- 
ence either what material we use as an envelope for the shield. 
Gum-elastic or cow teats are always clumsy, and easily become 
foul or hard, and sometimes taste in spite of our best efforts. A 
soft linen rag, properly adjusted over the draught-tube, is better 
and cleaner than any other envelope. It has the advantage of 
being cheap and always at hand, and so abundant that it may be 
replaced by a new one after each operation of sucking. 



TREATMENT OF MAMMILLITIS. 493 

But a very ingenious contrivance is mentioned by M. Legroux, 
which I will describe : 



R. 


Collodion, . 


. ppts. XXX 




01. ricini, . 


" ss. 




01. terebinth, 


. " jss. 




Mix. 





This is a fluid mixture, which is quite adhesive, and dries less 
quickly than collodion. It is applied upon the areola with a 
brush, so as to encircle, but not touch, the nipple, the width of an 
inch. While yet soft, the nipple is covered by goldbeater's skin, 
and pressed well down around it upon the mixture. The skin ad- 
heres to the adhesive material, and thus forms a perfect, smooth, 
and pliant covering to the nipple. All that remains to finish it, is 
to prick several holes through the goldbeater's skin with a needle 
to let the milk through. This has the advantage of not changing the 
shape, size, and feel of the nipple to the mouth of the child, so 
that it sucks more readily than it would an artificial nipple made 
with a common shield. But while this is the case, it allows the 
pressure of the lips upon the nipple at every point, and only par- 
tially relieves the mother from the pain. 

In most cases I would rely more upon the judicious selection 
and management of a shield than this contrivance, ingenious and 
neat as it is. This may be imitated by other adhesive mixtures 
and tissues. Before sucking, the goldbeater's skin must be moist- 
ened with a little sugar and milk. Much of the suffering under 
nursing, while the nipple is raw from chaps, abrasions, or ulcera- 
tions, may be avoided by being drawn by the mouth of an adult, 
so shaping the vacuity, produced for the purpose of drawing, as 
not to touch the sore part. If the lips are so placed around the 
nipple as to press upon the areola and not touch the nipple more 
than very gently, — and I am sure this is practicable by any intel- 
ligent adult who will make a persevering trial, — the draught can 
be accomplished with comparatively little pain. Violent action 
should not be used ; a gentle but constant pressure with the lips 
on the areola, with persevering but very gentle draught, will 
usually suffice, and powerful suction is sure to aggravate the cause 
of the retention of milk. I have often sat down, and by encircling 



494 DISEASES OF THE MAMMAS : 

the nipple with my fingers without touching it, and pressing upon 
the areola, caused the milk to flow freely, when, with great diffi- 
culty, it could be drawn out. In thinking upon this subject, we 
should remember that it is the pressure of the atmosphere upon 
the outside of the breast, combined with the elasticity of the in- 
teguments and coats of the milk-reservoirs, that urges the milk 
forward through the nipple into the vacuum caused by excluding 
it from around the top of the nipple. The vacuum will not be 
necessary, if the pressure can be made with sufficient firmness with- 
out injury of the part. Why may not some ingenious individual 
invent a milking apparatus of gum-elastic, that would act by press- 
ing upon the areola and front of the breast without causing a 
vacuum on the nipple ? This would often save a great deal of 
trouble and suffering to our patients. In thus viewing and treat- 
ing the subject, we would push the milk out instead of, as we, 
upon a superficial look at the matter, suppose, pull it out. 

The above palliative means do not enable us to avoid the causes 
of inflammation of the nipple ; but by their use we may render 
the operation of them less mischievous, which is often sufficient, 
in favorable cases, to effect a cure. In considering the curative 
remedies for sore nipples, I must protest against the simplicity 
with which we use the term, and think of, sore nipples. We speak 
and think of it as though there was no variety of sore nipples. 
The same treatment is not applicable to abrasions, that is, to 
chaps or cracks, nor to ulceration, nor to all the conditions of ul- 
ceration. Nature tries to cure cuticular abrasions by an effusion 
upon the naked surface of a viscid albuminous layer, thus defend- 
ing the delicate tissue from contact with atmospheric air, or other 
irritating substances; and if this is allowed to remain undisturbed, 
it will as it falls from the place, leave a well-formed delicate cuticle. 
And I think the nearer we imitate nature in this respect, the more 
good we will do. We may use starch or mucilage to cover the 
abrasions, but any astringent or stimulant application is inadmis- 
sible. Abrasions, however, do not last long without becoming 
ulcerated, and the treatment may be different. When there are 
numerous fine chaps, covering a large surface of the nipple, or 
when single, if very shallow, the treatment for abrasions will 
usually answer every purpose. Ointments of a mild, unirritating, 



TREATMENT OF MAMMILLITIS. 495 

or even a soothing quality, are probably more applicable than in 
abrasions. The following is a very good one: 

R. Cerat. alb., - . gij. 
01. amyg. dulc, . gj. 
Mel. desp., . . !§ss. 
Mix. Dissolve with gentle heat, and add Bals. Canad., gijss. 

This should be applied every time after nursing. When the cracks 
are deep, it is indispensable to quick cure that they should be 
closed up, and kept so until complete adhesion of their sides takes 
place. This may usually be done with great facility in the follow- 
ing manner, viz. : press the nipple in such a way as to close the 
crack, and while thus holding it, apply a thick layer of collodion 
over the surface. We should apply the layer thickly, and have it 
extend some distance in every direction, so that it will keep the 
crack together. The collodion is not easily sucked off by the 
child, and if the nipple-shield be used, it need not be disturbed at 
all until completely healed. We should watch the coat of collo- 
dion, and remove it when it seems to be becoming deficient by vio- 
lence of nursing. In most cases this covering, if kept up un- 
broken for a week, will suffice to complete a cure, if suppuration is 
not going on in the chapped place. If this is the case, and the 
surface becomes an ulcerated one, it will fill up by granulation 
alone, and falls into the category of ulcerations. In this part of 
the body, ulceration does not differ from the conditions it assumes 
in other places ; and it cannot be expected that I should dwell 
upon every variety that may occur. General principles must guide 
us here as elsewhere. There are two conditions, however, one of 
which is apt to obtain a prominence and give character to this 
ulcer, — acute and chronic ; in either of these conditions, the ulcer 
may be exceedingly irritable to the touch, and painful; and in the 
latter, indolent and atonic. The acute variety is apt to be attended 
with considerable heat, tumefaction, color, and tenderness. These 
conditions should be removed by depletion, as by leeches, — one or 
two will generally do, — cold emollient poultices, large enough for 
the nipple alone, and removed as often as they become warm. Or 
we may envelope the nipple in a thin layer of thick mucilage, 
covered by oil-silk, so as neatly to fit the organ, kept cold by ice 
applied in a small bladder or India-rubber bag, or we may wrap 



496 DISEASES OF THE MAMM^ : 

the ice in oil-silk. In whatever envelope it is used, it should not 
extend beyond the inflamed part, and should be separated from it 
by a thin layer of cotton-wool, or something of that kind. 

When such remedies are not necessary, because of the non-exist- 
ence of these symptoms, we should content ourselves, in the very 
early stages of ulceration, with similar mucilaginous and bland 
ointment applications as in abrasions ; but as the process goes on, 
and the acute symptoms entirely subside, astringents become useful, 
and these will vary in character and strength according to indica- 
tions of atony and flabbiness, &c. Alum and tannin are excellent 
applications at first, but will have very little effect after the ulcera- 
tion has continued for any great length of time. Sulphate of zinc 
and borax will come next in respect to time. One scruple of tannin 
to one ounce of rose-water, five grains of alum, the same quantity 
of sulph. zinc, are all good in the earliest stages of ulceration of 
the nipples. When the more acute symptoms have subsided, the 
following formulae are often very useful : 

R. Glycerine, . . . . gij. 
Sodse subboras, . . . gss. 
Aquae rosse, .... ^jss. 
Mix. Use as a wash each time after sucking. 
Or, 

R. 



Sodse subboras, 


• StJ 


Cretse prep., . 


• Ih 


Spts. vini, 




Aquae rosse, aa, 


• '%% 


Mix and dissolve. 





This last may be used when the ulcer is becoming somewhat 
indolent. Tinct. kino, tinct. nutgalls, and, in fact, almost every 
astringent, has been used in these ulcers. In chronic ulcers, 
still stronger astringents or stimulants will become necessary in 
conjunction with other remedies. A skilful use of the sulph. 
cupri and nit. argent will do a great deal to heal up and shorten 
the course of these chronic ulcers. The nitrate has done the most 
good in my hands. It should be applied in substance to the sur- 
face of the ulcer, and never be used oftener than once in eight 
days, when a second application becomes necessary. Between 
times, the ulcer may be dressed with some of the milder astrin- 
gents, alum or tannin, for instance, in solution. In the irritable 



TREATMENT OF MILK ABSCESS. 497 

variety, some narcotic extract should be made into ointment, — bel- 
ladonna, hyoscyamus, opium, &c. An excellent expedient, and 
one that will often entirely change the character of these ulcers, 
is to anaesthetize the part with ice, as is directed to be done on a 
part before the performance of an operation. 

We are very apt, after we begin to use curative measures, to 
neglect the palliative. This is a great mistake, for they can have 
but little good influence while the causes are allowed to act with 
all the power that is necessary to produce the disease. We cannot 
attach too much importance to the measures of palliation. 

Treatment of Inflammation of Lymphatic Glands. — The causes 
of lymphatfc inflammation should receive our attention first, as the 
abraded or ulcerated nipples, inflamed areola or integuments of 
the breast, or, when chronic, the constitutional condition in addi- 
tion to the local excitements. When acute they will require, in 
addition, the antiphlogistic measures adopted in other inflamma- 
tions, — leeches, cooling lotions, fomentations, cathartics, &c. ; when 
chronic, alteratives, iodine, tonics, liniments, irritants, &c, which 
will be adapted by every physician, according to his own judgment, 
to the peculiarities of his case. If we are accurate in our diag- 
nosis, and separate this affection from those of the deeper-seated 
structures, there will be no great difficulty in adjusting the treat- 
ment of it. 

The treatment of milk abscess is one, however, of greater impor- 
tance, because of its frequent occurrence and destructive effects. 
The remedies naturally range themselves into preventive and cura- 
tive. The preventive has reference to the management of the 
anatomical and pathological conditions of the nipple, which pre- 
vents the free elimination of the milk. Of the latter, I have 
written quite as extensively as the limits of this work will allow. 
Can we change the anatomical deficiencies or depraved shape of 
the nipple, of congenital or acquired origin ? It is a matter of the 
utmost importance to the health and happiness of the patient, that 
this question should be decided promptly and properly. Much 
will depend whether our attention was drawn to the case early in 
pregnancy, or not until the time of labor, or even afterwards, as 
to the probability of success in many cases. In other cases, we 
can decide the nipple to be impracticable at the first sight, at 
whatever time we examine it ; and I would insist upon the im- 

32 



498 DISEASES OF THE MAMM^ : 

propriety of compelling a woman to pass through the terrible 
pain and exhaustion which attend these cases, where the nipple, 
for instance, is entirely wanting, and prehension impossible. If 
our attention be not drawn to the nipple until after labor, and the 
functions of the breast are required, we ought not to hesitate 
to decide against nursing, or attempting it ; and so far as I am 
concerned, individually, I would advise against the endeavors to 
use the breast represented by Fig. 27, if I was aware of its 
condition at the beginning of pregnancy. Fortunately, this de- 
ficiency is rare. When there is an approximation to this, but not 
complete absence or depression of nipple (the breasts shaped like 
Figs. 28 and 29), much may be done toward rendering them use- 
ful, provided our efforts are judicious, and sufficiently prolonged. 
They should be commenced as soon as pregnancy is known to 
have taken place ; and if in the state of society it were practi- 
cable, the prospect of success would be much better, could* we 
have the management of our patients as soon as menstruation be- 
gan. If mothers were well instructed in this matter, and would 
carefully attend to it, the probability is, that almost no cases of 
anatomical unfitness for nursing would present themselves. 

Flat or undeveloped nipples (Figs. 28, 29, and 30), if not ob- 
served by the practitioner until after parturition, will be almost 
certain to give him trouble, and he will be scarcely able to prevent 
extensive milk abscesses. The first and most important principle, 
is to take perpendicular pressure entirely off the top of the nipple, 
and this would probably be sufficient to prevent the difficulty, if 
complete. This little projection, on account of the fashions of 
female dress, is kept constantly pressed back into the soft yielding 
mammary tissues, until it becomes hopelessly imbedded into them. 
Now what we want is to counteract and remedy the effect of this 
mischievous habit. A number of devices have been resorted to for 
the purpose of starting the nipple forward from its imbedded con- 
dition. They have for their object, as a general thing, the pro- 
duction of counter pressure around the nipples, upon the areola 
and central portion of the breast, in such manner as to press the 
central tissues beneath the nipple, and thus cause it to protrude. 
If this object can be effected by such gentle means, continued 
for a sufficient length of time before the birth of the child as 
to make it a permanent state of this organ, the treatment will 



TREATMENT OF MILK ABSCESS. 499 

be effective. The misfortune is, we can seldom get the important 
desideratum, time, and we are under the necessity of beginning 
our treatment often too late to effect anything. When called upon 
to remodel a nipple before or during pregnancy, we may make use 
of a shield of stiff silver, or iron wire, large enough to embrace 
and actually fit the anterior surface of the breast, with a cap-like 
projection from its centre, into which the nipple may project. 
There may be some soft substance, very thin cotton or wool, to 
protect the surface from the wire placed immediately beneath it. 
This should be worn for months under the dress, and receive all 
the pressure from it, and distribute it over the front of the 
mamma, and protect the nipple from any pressure. Such a shield 
is far better than ivory, wood, India-rubber, or any other imper- 
meable substance, as it does not interfere with the transpiratory 
functions of the skin, or the secretion of the areolar follicles and 
glandulse. 

When we are not called upon to treat these rudimentary nipples 
until the time of or after parturition, such treatment will not avail. 
The effect must be brought about more promptly, on account of 
the necessity for immediate use. In many cases the nipple can be 
made available by temporarily inducing its erection by simple titil- 
lation with the finger, moving it gently around it, and then imme- 
diately applying the child. An excellent way of erecting the 
nipple, when there is considerable depression, is to place a thick 
layer of collodion around it on the areola. When this dries and 
contracts, the nipple will be elevated quite prominently ; the child 
should then be placed to the breast, and allowed to nurse. 

When the nipple is protruded in some of these ways, the milk 
may usually be drawn, so as to more or less completely empty the 
reservoirs. This will prevent milk abscess very generally. When 
inflammation of the reservoirs has fairly begun, it will be exceed- 
ingly difficult to prevent suppuration. The curative means consist 
in thoroughly evacuating and keeping empty this set of vessels. 
Several modes of doing this have been recommended, such as 
drawing with a glass tube shaped like a pipe. Various shapes of 
breast-tubes and pumps are in use, but I must object to all of these. 
It is a very easy matter to injure the delicate tissue of the breast 
by the hard rim of these instruments, and I think the accident 
often happens. 



500 DISEASES OF THE MAMM^l : 

A puppy is often brought into requisition for this purpose, but 
is rough, and sometimes irritates the nipple and even sucks the 
skin off it. The oilly proper thing for drawing the milk is the 
mouth, and when these reservoirs are inflamed, it should be the 
mouth of an adult, who can vary the pressure or force to suit the 
tenderness of the part. Another very useful class of measures are 
those intended to suppress the secretion of the milk, and thus re- 
lieve the reservoirs from the distension. The narcotic substances 
taken internally, or applied externally to the breast, do a great 
deal towards stopping the secretion of the milk. Opium in large 
doses, so as to keep the patient very thoroughly under its influ- 
ence, aids very much in arresting the secretion of milk. Applied 
externally in ointments, so as to produce a decided impression 
upon the system, it has a similar effect ; but belladonna seems to 
have acquired most renown for this purpose. Mr. Richard Mar- 
ley reported forty cases to the Obstetrical Society of London 
treated successfully by inunction of belladonna. Dr. Tanner cor- 
roborates Mr. Marley's conclusions by his own experience. Amer- 
ican physicians testify in favor of belladonna by furnishing to 
medical periodicals a great many favorable cases within the last 
two or three years. It should be remembered that many of the 
extracts sold in the shops, if not entirely inert, are at least much 
below the standard in strength. Our opinion of the efficacy of 
these, of course, will vary from this circumstance, and hence, 
doubtless, the discrepancy in the testimony of different observers 
in regard to the use of belladonna for the purpose of suppressing 
the secretion of milk. The inunction of ointment made with the 
extract should be carried to a sufficient extent to produce some of 
its characteristic effects upon the system. Its use should be as 
profuse as the system will well bear. Cold, as a local application 
in cases of milk abscess, has several good effects. It anaesthetizes 
the part, rendering the patient more comfortable ; it decreases the 
secretion, constringes the reservoirs of milk, and allays excite- 
ment in the capillary circulation. In supplying cold to the breast, 
the temperature should be about forty or forty-five degrees, and 
kept as steady at that as possible. Water of that temperature 
might be kept running through an India-rubber bag enveloping the 
organ. A bladder partly filled with ice and water, with a piece of 
flannel between it and the skin, would also do very well. When 



ACUTE INFLAMMATION OF MAMMARY GLANDS. 501 

we do not desire to promote secretion of milk, cold may be used. 
I do not believe there is any danger from it while its application 
is confined to the part affected, and its bad effects are usually pro- 
duced by wetting the clothing, or allowing it to get applied to 
other parts of the person. I cannot express with sufficient force 
the evil effects which the prejudices of a former age in medicine 
have fastened upon the minds of at least a part of the public in 
the practice of keeping the breasts wrapped in thick layers of cot- 
ton or lamb's wool. It is promotive of the secretion of milk by 
drawing blood to the gland, and thus keeps up the state of things 
we desire to avoid. For internal treatment, a saline cathartic 
every other day, and two grains of iodide of potassium every four 
hours, may be relied upon as materially aiding the other treatment. 
In this affection, antiphlogistic treatment is merely auxiliary, and 
should not be pushed to an extent usually considered necessary in 
other inflammatory affections. In this case, over-distension is the 
cause of the inflammation, and its removal in the early stages is 
generally sufficient to cure. 

Treatment. — Acute inflammation of the glands of the breast, 
when it occurs as the effect of congestion immediately preceding 
the secretion of milk, is apt to be very extensive, sometimes in- 
volving the whole of the gland, and will require energetic treat- 
ment. For the first few hours we should try warm fomentations 
with the hope of establishing the secretion. This probably would 
be unavailing if actual inflammation had begun ; but we cannot 
always determine the point when this intense congestion passes 
into inflammation, and hence we are justified, I think, in making 
the effort. If the patient is robust, and the fomentations fail 
wholly or partially to bring relief, a decided venesection will often 
turn the balance in favor of resolution. When we bleed, the ob- 
ject should be to produce a decided impression, and in order to do 
this the patient should be in a sitting posture, and the blood al- 
lowed to run until the pulse is affected and syncope approaches. I 
have so much faith in verat. viride in combating inflammation, that 
I begin its use immediately after venesection, and if the patient is 
strong, give it in six-drop doses every four hours until the pulse is 
brought down to sixty in the minute, and then, by administering 
it in decreased doses, keep it as nearly at that as possible. One 
grain of calomel, with a quarter of a grain of sulph. niorph., may 



502 DISEASES OF THE MAMM^ : 

be given occasionally, if the pain is urgent, every four or six hours. 
This kind of promptitude and energy of treatment will frequently 
arrest the inflammation and bring about resolution. And when 
we remember the amount of suffering and damage it may prevent, 
nothing should deter us from urging our patient to accept the 
treatment. Should this not be sufficient, it is an important ques- 
tion whether depletion can be carried further. One good full 
general bleeding, if followed by veratrum, will be sufficient gene- 
rally, but sometimes it will be expedient to use leeches, and pro- 
duce a general alterative mercurial influence. A lotion made of 
one part of sulph. ether to two parts of alcohol, will be a good 
soothing adjunct after the inflammation becomes permanent. If 
the inflammation begins later, the extent of disease is apt to be 
less, and may be confined to one lobule, or, at most, a part of the 
gland only. In this case, a brisk cathartic of calomel, aided by 
some saline, leeches to the part, followed by cold lotions, tinct. 
verat. viride, or solution of tart, ant., given at sufficient intervals 
in proper quantities, will afford us efficient treatment. If this 
treatment is begun early we may expect much good from it. It 
has always been an interesting question w T ith me, after the inflam- 
mation has existed for a length of time, and we cannot avoid the 
formation of pus, whether we should abandon antiphlogistic means 
and resort to warm poultices and fomentations, to promote suppu- 
ration. I think that this is not justifiable in many instances. The 
probability is that if w r e continue our general and local antiphlo- 
gistic treatment until suppuration is clearly evident, we may limit 
the extent of that termination, lead to resolution in a larger part 
of the gland than would otherwise take place, and thus save much 
of the glandular tissue. When the whole gland is inflamed, there 
is no necessity, in fact, I think it injurious, to institute and con- 
tinue strenuous efforts to draw the breast. There is little or no 
secretion, and when a part of the gland only is inflamed and milk 
is produced by the rest of it, it is questionable whether anything 
but the most moderate means for this purpose are admissible. Re- 
tained milk is not the cause of inflammation in this case as in milk 
abscess. Very frequently glandular inflammation is complicated 
with inflammation of the reservoirs. Then we must combine our 
treatment to suit the case, local and general antiphlogistic, with 
means to arrest the secretion and empty the reservoirs of the milk 



ACUTE INFLAMMATION OF MAMMARY GLANDS. 503 

already contained in them. Chronic inflammation of the gland 
will be cured by much the same treatment successful in other 
glandular inflammations of this grade, — leeches, mercurials, iodine, 
and vegetable alteratives, perseveringly administered internally and 
locally applied. Much reliance can be placed upon well-regulated 
and graduated pressure, with adhesive straps, pressing the part 
diseased against the ribs, or collodion encasing the breast thor- 
oughly. When suppuration has taken place, what are the indi- 
cations to be relied upon to justify us in evacuating it? There 
can be no doubt, I think, that the earlier the matter is let out the 
better, for several reasons. The cavity becomes larger by allowing 
it to remain ; it burrows through the surrounding tissues. The 
longer it remains the greater the amount and duration of the 
irritative fever that accompanies its retention. But, notwithstand- 
ing the desirableness of getting rid of the pus, we should hesitate 
to cut through the uncondensed tissue to any extent. In cases where 
the inflammation and suppuration are deep in the gland, it is de- 
sirable to wait until the pressure from within has lasted long 
enough and in a sufficient degree to cause the condensation of the 
tissue. Otherwise, it will require a very large opening to allow a 
free discharge. I think we should pot lance the part until fluc- 
tuation is quite evident, and the pus has made its way to the fascia 
or integuments. It is never desirable to cut through any part of 
the uninjured gland or milk-ducts, and, altogether, I should feel 
more inclined to allow it to approach the integuments very closely 
before cutting. 

In the case of milk abscess, the earlier the opening is made the 
better. As soon as it is evident that suppuration is inevitable, the 
opening may be made. The smaller the opening to allow the 
escape the better. Should the disease still exist that caused the 
retention, the opening should be preserved. Often the evacuation 
of one or two reservoirs will suffice, and the rest will continue to 
discharge through the nipple. The effect of suppuration and 
evacuation of a milk-reservoir is often to entirely destroy its cav- 
ity, but in other instances it continues to discharge through the 
artificial opening, and a milk-fistula remains. This may be closed 
by an occasional application of the nitrate of silver in pencil. 
Worse than these are the tortuous lacunae, that sometimes result 
from the deep glandular abscess of the breast. They are gener- 



504 DISEASES OF THE MAMMiE : 

ally difficult to cure. Injection of iodine is the remedy most re- 
lied upon for these troublesome sequences to suppuration. The 
most effective way to inject is to insert a soft flexible catheter, if 
possible, to the bottom of the twisted canal, and throw the injec- 
tion through it, so as to apply it without dilution to the bottom of 
the pus fistula. I think this important when practicable, because 
it favors the shallowing instead of the narrowing of the cavity. 

Of course it is never advisable to slit up these obstinate purif- 
erous ducts in the breast, as it sometimes is in other parts of the 
body, because of the amount of tissue that might be damaged which 
it is desirable to save. 

Chronic Inflammation of the Breast. — Inflammation of the 
breast, instead of pursuing this definite and decidedly phlogistic 
course, proceeds with such gentleness, and so slowly, as to render 
its diagnosis obscure ; and there is no doubt but that we meet with 
instances in which a correct diagnosis, at the time we first see the 
case, is quite impossible. These instances are not numerous ; and 
a careful examination of all the conditions enables us to come to 
positive and correct conclusions. 

Symptoms. — The inflammation begins, in some instances, with 
an obvious degree of pain, giving the patient inconvenience that 
is almost constantly experienced, or the pain and soreness are no- 
ticed only at intervals. In other cases there is no pain whatever. 
The first indication of the disease is the discovery of tumefaction 
in some accidental way. When examined, there is no discolora- 
tion at all in many cases, in some again but slight. If the tumid 
part is examined by the test of touch, the patient experiences 
but slight inconvenience from considerable pressure. And in or- 
der to discover tenderness, pressure must be made in every direc- 
tion, when, in some particular place, or by pressing in some par- 
ticular direction, the patient will complain of tenderness, generally 
deep-seated. I have occasionally been able to elicit complaints of 
tenderness, by pressing behind the tumor, or attempting to lift it 
up from the chest. The tenderness is generally deep-seated and 
obscure, but I believe I have not met with a case in which there 
was an entire absence of it when thus carefully tested. 

When the tumidity is first discovered, it may be very small, not 
larger than a hazel-nut, and never attain to any great size ; or it 
may-increase very much, so as to involve a large part of the breast. 



CHRONIC INFLAMMATION OF THE MAMMARY GLANDS. 505 

It may also commence by implicating a large part or the whole of 
the organ. The cases I have seen have nearly all been large. 

It may require only a few months for the disease to run its 
course to suppuration and exulceration ; but sometimes several 
years are consumed in these slow steps, as many as three, four, or 
even five. In connection with the deep inflammation, we some- 
times witness inflammation of the skin and integuments. It occa- 
sionally proceeds to discoloration and considerable ulceration, and 
must be regarded as a complication, and not a part of the deep in- 
flammation, unless we consider them both the results of a general 
scrofulous diathesis. 

It occurs almost invariably during the childbearing period, 
and is more frequently discovered during the time of nursing. 
The patients are usually persons of feeble, broken-down, or im- 
paired constitutions, with a thin, unhealthy state of the blood, and, 
many times, of tuberculous tendencies. Sometimes, however, we 
meet with it in robust persons, to all appearance sound and healthy. 
In these patients we generally have more of the inflammatory 
symptoms. From the fact that this chronic inflammatory tumor 
makes its appearance generally in weak, unhealthy patients, it is 
sometimes called scrofulous tumor of the breast. 

Diagnosis. — It occurs in the nursing, — not in the aged, as does 
cancer, nor in the sterile and single, like the adenoid tumor. The 
patients are under forty years of age. It is always tender, if 
properly examined, by lifting up, shaking, or pressing in every 
conceivable manner. This is not the case with cancer, the adenoid, 
or encysted tumors. Sometimes the parts are discolored in can- 
cer and chronic inflammation. In cancer, tenderness and discol- 
oration do not correspond : they do in inflammation. If there is 
much discoloration in the inflammatory tumor, there is considera- 
ble tenderness ; but there is not much tenderness, however purple 
and dark the skin may become, in cancer. The inflammation com- 
mences softening in the centre, and the soft part is surrounded by 
hardness completely, showing hard inflammatory walls. Cancer 
softens irregularly, and generally contemporaneously with exul- 
ceration. There is, at most, very doubtful fluctuation in cancer. 
In chronic inflammation there becomes evident fluctuation for a 
considerable time before exulceration. The adenoid tumor does 
not soften except under the process of inflammation. Xhe diag- 



506 DISEASES OF THE MAMMiE : 

nosis may be rendered demonstrative by the exploring needle in 
the discovery of pus. 

Prognosis. — The prognosis is always favorable. The patients 
will get well spontaneously; or may be more readily cured, pro- 
vided there is not fatal complications connected with it. 

Treatment. — In robust patients, the treatment should be anti- 
phlogistic and alterative : massa hydrarg., grs. x, every fourth 
night, to be followed in the morning by a saline laxative. Ano- 
dynes at night, if the patient is in much pain, are also admissible. 

In patients whose constitutions are impaired by long suffering, 
tonics should be added to a gentle alterative medication. The 
bowels should be kept regular by the above course of alteratives. 
If the stomach is debilitated, the bitters, as infusion of gentian, 
cinchona, serpentaria, quassia, as they may agree with the pa- 
tient ; to which, if acidity be troublesome, some form of alkali, as 
carb. soda or potassa, may be added. Iron should not be omitted, 
unless some peculiarity forbids it. Cod-liver oil not unfrequently 
does better for these cases than any other medicine. It is not 
often retained without combining with a stomachic or stimulant, 
and should always be given after meals, as it will do more harm 
by the nausea it produces than good. 

The local treatment should be conducted with a view to promote 
the discharge of the pus. Poultices of bread and water, or bread 
and milk, linseed meal, or other emollient, will suffice for this, if 
persevered in sufficiently. Soon as fluctuation is evident, the pus 
should be evacuated by puncture, and its evacuation be encour- 
aged by poultices. 

Mastodynia, Mastalgia, Neuralgia of the Mamma?. — This is a 
true neuralgic affection of the breast, unattended by permanent 
structural disease of the parts. Sometimes both mammae are af- 
fected simultaneously, but very often the pain is confined to one ; 
and singular as it may seem, the left side is most frequently at- 
tacked. When both mammae suffer, one is pretty sure to be more 
painful than the other. Sterile married persons, or single women, 
are the most common subjects of this affection ; and it generally 
occurs between the ages of sixteen and forty. The menstrual 
period exercises a perceptible influence upon it, making it much 
worse ; and, in many instances, only at this time is the pain expe- 



NEURALGIA OF THE MAMMJ!. 507 

rienced. Pregnancy sometimes either originates or aggravates 
the pain. 

The general health of patients in whom mastalgia is observed, 
is usually feeble ; they are often nervous, and often broken down 
in constitution. They are subject to menstrual irregularities of 
some kind, displacements, inflammation, or some other diseased 
condition of the uterus } and there is no doubt in my mind that 
neuralgia of the mammae is secondary, and that it originates in 
uterine or ovarian disease. It is certainly possible that this pain- 
ful affection may be primary or idiopathic in some instances, but 
such must be very rare, and I have never seen any such case. 

Symptoms. — The pain varies in intensity, in different instances, 
from mere inconvenience to severe suffering. It is sometimes con- 
fined to the mammae, but often it radiates to the shoulder, axilla, 
down the side, into the chest, up the side of the neck, and down 
the arm. The character of the pain is not always the same. It 
will sometimes be a sense of painful tenderness, but generally the 
pain is neuralgic. Sometimes the breasts are tumid, and not un- 
like in appearance the post-partum breast; sometimes there is a 
distinct lump, which seems to be the point whence the pains origi- 
nate, and occasionally the axillary glands are tender, enlarged, 
and the seat of the same kind of pain as the breast. In a large 
number of instances, the mammae undergo no apparent change. 

With all this there may be neuralgia elsewhere, as in the face, 
head, back, extremities, &c. The individual attacks of masto- 
dynia last ordinarily several days, sometimes a week or more ; 
and the attacks recur for months, and even years, with an obsti- 
nacy difficult to overcome. 

Prognosis. — Hence the prognosis, so far as ready relief is con- 
cerned, is not very good; but on the other hand, the disease never 
endangers the life of the patient. In this connection, however, 
it should not be forgotten that it is occasionally accompanied with 
fatal disease of the uterus, as cancer, for instance, and although 
not in itself fatal, is indicative of mortal mischief somewhere else. 

Treatment. — The treatment is palliative and curative ; and al- 
though this last is not as effective as we might wish, in many in- 
stances, yet in the majority of cases a cure may be effected. Dur- 
ing the paroxysm the various anodynes used, locally and generally, 
may be made to mitigate the suffering very materially. The bel- 



508 DISEASES OP THE MAMM.E : 

ladonna plaster, or a plaster of equal parts of ext. belladonna and 
powdered camphor gum, may be applied as a good local anodyne. 
Ointments containing chloroform, opium, and narcotic extracts, 
are useful in allaying the suffering. If these are not sufficient, 
internally the same remedies are more effectual. The tinct. of 
gelsemin, or the resinoid, may be used with the hope of relief. 
The resinoid prepared by Keith, in quarter of grain doses, may 
be given every four hours until vertigo is experienced ; or four 
grains ext. hyoscyamus, with an equal quantity of gum camphor, 
given every four or five hours, will often give relief. Should these 
fail, opium in substance will pretty certainly bring the required 
ease. As a general thing, the pains of mastodynia are not so ex- 
cruciating as to make it necessary to resort to active anodyne 
medication, and it should be avoided if we can. 

The curative treatment is constitutional and local. The consti- 
tutional should be conducted with a view to the correction of any 
constitutional depravity. The patient is usually weak, the stomach, 
liver, and bowels, need correction, and sometimes the skin and 
kidneys do not discharge their functions in a healthy manner. 
Small doses of hydrargyri, in the shape of blue pill, calomel, or 
corrosive chloride, should be given every three or four days. The 
bowels ought to be kept free by Rochelle salts, aloes, or rhubarb, 
owing to the state of the secretions. If the passages are dry and 
hard, the salts will do best; but if the bowels are simply slow, a 
combination of aloes and rhubarb will do better. The tonic course 
should be a mixture of vegetable bitters and iron. Infusion of 
quassia, or gentian, or the compound tinct. of cinchona, imme- 
diately after eating, followed by tinct. of iron two hours after 
eating, three times a day, will very generally agree well. Some- 
times with the bitter infusion, instead of iron, ten or twelve drops 
of the liquor potassa will do better. If the urine is highly acid, 
this alkali is decidedly indicated. The iron may be given in pill 
if the tincture should be offensive. We not unfrequently find it 
impossible to administer ferruginous preparations to these patients, 
on account of their causing headache, or an increase of the nerv- 
ous symptoms. This will not often be the case, however, if the 
bowels are kept sufficiently free, and the secretions in good condi- 
tion. We should try it in very small doses, and when it fails us 
entirely, we have an excellent substitute in arsenic. Two or three 



AGALACTIA. 509 

drops of Fowler's solution, given some hours after the bitter infu- 
sion, or tincture, will often produce a very happy effect. If we 
can succeed in bracing up the system in this way, we may some- 
times relieve the sufferer entirely ; bat almost always the benefi- 
cial effect of this treatment is only temporary, and the patient is 
not cured until the state of the uterus upon which the mammary 
suffering depends is removed, and then it entirely and permanently 
disappears. I have seen this occur quite often. 

It will here be necessary only to counsel the student to make a 
thorough examination of the condition of the genital organs, and 
when anything wrong exists to rectify it. In proportion as the 
accomplishment of this last part is complete, will be the relief of 
the neuralgia of the breasts. The local treatment, as well as the 
mode of examination, will be found in another part of this work. 

Agalactia — Absence of the Secretion of Milk. — This affection 
may be met with in two different forms, viz., when the milk fails 
to make its appearance after confinement, or ceases to be secreted 
during the ordinary term of lactation. 

The local conditions which cause agalactia are deficiency of the 
formation of the gland, inflammation, or injury of it by accident. 
Many general circumstances will produce the same effect, as fever 
of various kinds of long duration, depressing passions, want, ex- 
posure to cold, &c. 

The suppression of the secretion during lactation may also take 
place as the result of pregnancy. It may be further stated that 
any disease, accident, or other cause, producing a powerful delete- 
rious general influence, will occasionally have the same effect. 
The suppression of the secretion of milk, so far as I am aware, 
does not produce disastrous effects of any kind upon important 
organs ; and I am persuaded the consentaneous evils, as tubercu- 
losis, &c, which are said to be the result, are more causative than 
sequential. 

Agalactia is generally an obstinate difficulty. Of course it is 
irremediable in cases where the gland is deficient. And great per- 
severance is often required to induce a good state of lactation in 
persons who have commenced childbearing at very late periods in 
life. 

Treatment. — Well-directed and persevering efforts at suction, 
with the child's or other person's mouth, is one of the most effec- 



510 DISEASES OF THE MAMM.E : 

tive as well as entirely natural stimuli to the flow of milk. The- 
child should be applied at intervals of four or five hours for a 
number of days. In the intervals of nursing the breasts should 
be oiled and fomented with •warm water, or poulticed with some 
warm emollient substance. A thick pancake applied warm, and re- 
placed with another soon as it becomes cool, is an excellent means 
of promoting the secretion of milk. They should be persevered 
in for one or two weeks, or until the secretion is established. We 
are recommended by almost every medical work on the subject to 
use the leaves of the castor-oil plant (Bicinus communis) wilted in 
hot water, and' applied warm over the breasts, changing them as 
they become cool, or to foment the breasts perseveringly with a 
strong decoction of them. It is a popular belief that they have a 
specific effect in causing or promoting the secretion of milk. 

Electricity is also recommended as an excellent stimulus to the 
secretion of the mammae, as well as to that of almost all the rest 
of the organs. The continuous current of a galvanic battery of 
weak power, or the gentlest effects of the electro-magnetic appa- 
ratus in ordinary use, may be tried. The current should be so 
gentle that it is barely perceptible to the patient, and persevered 
in for several hours. The internal treatment is not very impor- 
tant, unless there is some very serious general disorder. Then, of 
course, the treatment will be governed by the indications presented 
in the case. What, perhaps, ought to have been mentioned in the 
treatment, is the removal of any of the causing conditions stated 
as producing this affection. Potations of some savory fluids in 
considerable quantities, when the secretion is once established, 
will aid in promoting its abundance. Chocolate, milk, and, if the 
patient is weak, lager beer, porter, ale, of the malt liquor kind. 
Soups and fluid diet generally may be used to the same end. 

Galactorrhoea — Unusual quantity of Milk, or long continuance 
of it. — Sometimes when the patient is nursing the flow is immod- 
erately great, and she is very much weakened by the excess. In 
other instances, the flow may be unusually great, and after the 
child ceases to nurse continue for a great length of time ; or, al- 
though the flow is not excessive, it does not cease when the child 
is weaned. In all of these varieties of abnormal secretion the 
general health of the patient will suffer in a greater or less degree. 

The conditions of the system upon which galactorrhoea depends 



GALACTORRHEA. 511 

are various. They all, however, seem to affect the blood to a 
greater or less extent. General debility is one of them, diseases 
of the uterus, indigestion, perhaps of a character to produce more 
than an ordinary amount of glucose. 

The prognosis is favorable so far as the ultimate termination is 
concerned, but the disease lasts for a great length of time some- 
times in spite of the most judicious management. It has been 
known to last for five years, as we are informed by Montgomery. 

Treatment. — The main object is to remove the causing condition 
when practicable. If the uterus is diseased, displaced, or other- 
wise in abnormal condition, it should receive special attention. 
Debility, so common an attendant, should be remedied when pos- 
sible by suitable tonics, alteratives, nutritious diet, proper exer- 
cise, &c. The preparations of iron, as the tinct. ferri chl., gtt. xx, 
three times a day, after eating, syrity of the iodide, in like quan- 
tities and at the same intervals, may be mentioned as especially 
adapted to the purpose. The cod-liver oil is also a good nutrient, 
taken in tablespoonful doses, combined with some alcoholic stimu- 
lant, soon after eating. As different cases will require some varia- 
tion owing to their peculiarities, and almost all practitioners have 
their own experience in the use of the roborant regimen and course 
of medicine, a good deal must be left to a discriminating judg- 
ment. 

But, in addition to the rational course suggested by the symp- 
toms and circumstances of the patient and attack, several reme- 
dies are recommended for their special effects in lessening or sup- 
pressing the lacteal secretion. Dr. Scanzoni calls them ischoga- 
lactics. The one that seems to be a favorite with the profession 
is the iodide of potassium. It may be given in three-grain doses 
every four hours in solution. Although I have repeatedly admin- 
istered this medicine with a view to its effects in suppressing the 
secretion of milk, my opinion of its efficacy is not positive. In 
some instances its effects were apparently moderately favorable ; 
in others I could see no effect whatever. I do not know whether 
it is entitled to a place as a remedy in this respect or not. 

With belladonna, however, the case is very different. It, too, 
will entirely fail in instances where we may expect it to succeed ; 
but in the majority of cases we may rely upon its efficacy, not 
immediately to suppress the secretion, but to aid rational treat- 



512 DISEASES OF THE MAMMJ : 

ment very materially. I have also seen decidedly good effects 
from sage (salvia). There is often an appetite for some such aro- 
matic substance, and when this is the case, I think it does more 
good for the patient to eat it in considerable quantities. We may, 
however, use a strong infusion of it as a drink and fomentation to 
the breast. The fomentation should be cold, as it has a much bet- 
ter effect when of that temperature. Ice has also a very decided 
ischogalactic effect. We may use it freely for some hours at a 
time. The mode I have almost invariably adopted is to put the 
ice in a bladder, partly fill it, and then lay it upon the breast, 
with thin flannel between. If the sense of cold is oppressive or 
disagreeable in any way, the breast may be kept covered with two 
thicknesses of flannel. If general chilliness occurs, we ought not 
to continue it. Although I have tried it in this way in quite a 
number of cases, I have not seen it cause glandular inflammation 
in any. Indeed, I think there is too much dread of cold to the 
mamma, and that upon more extended trial the prejudice will be 
dispelled. 

Cancer of the Breast. — This most malignant affectiQn appears 
in the breast in the form of scirrhus more frequently than in any 
other, although all the different varieties have been observed in 
this organ. Persons beyond or about the end of the childbearing 
age are most subject to it. Although persons above forty are 
much more frequently attacked, instances of a younger age are 
not unfrequent ; and even in quite young girls it sometimes occurs. 
Such cases almost always are of the medullary variety. A no less 
noted fact is, that childbearing women are the subjects generally 
selected ; the single and sterile, although not exempt absolutely, 
suffer much less from it. All parts of the breast are occasionally 
the points of inception : none so often as the gland, and the tis- 
sues contiguous to it. We may say, then, that it commences — 1st, 
in the gland ; 2dly, in the tissues surrounding ; 3dly, the nipple ; 
and, 4thly, the skin and integuments. When it attacks the gland, 
a portion of one lobe may suffer first, or the whole gland. When 
the nipple and skin are the places of beginning, the form is apt, 
but not always, to be cancroid, while the scirrhous and medullary 
form are found in the gland. 

Such a strong tendency exists in all forms of this affection to 



CANCER. 513 

implicate contiguous tissues, that the point of beginning is soon 
lost in the surrounding parts. 

Symptoms. — At the very beginning, the .patient may not expe- 
rience much pain in the part affected ; in a short time, however, 
the peculiar pain is experienced, — a sharp darting paroxysm, last- 
ing only long enough to create an excruciating perception, and 
then subside into complete ease. These pains are in the part, and 
seem to extend in some direction from them. At first they may 
not occur oftener than three or four times in twenty-four hours ; 
but as the disease advances they become much more frequent, 
until they cause sleepless nights and suffering days. 

These are the pains of scirrhus more particularly, but they oc- 
cur likewise in the medullary, less frequently and later. I do not 
know that they are experienced in the cancroid variety. As the 
disease advances, a distressing weight and distension are com- 
plained of; and as soon as ulceration is fairly established, new 
kinds of pain may be looked for as the result of the exposed con- 
ditions of the deeper structure, the excoriations and inflammation 
from the discharge. 

A wide variety of suffering from scirrhus will be observed, and 
no doubt is caused, by the different susceptibility of persons. Some 
have almost no pain, certainly complain of very little, while others 
suffer excruciatingly almost from the commencement. 

When the attention of the patient is first directed to it, we may 
find a small or large lump deeply seated, or near the surface, to- 
ward the margin, or in the centre, in the case of scirrhus ; gener- 
ally in the beginning movable, but very soon it becomes attached 
to the neighboring parts above, below, or at the sides, while it may 
be made to glide over parts in every other direction. As the case 
advances, the attachment becomes general, and the part affected 
fixed among the neighboring tissues. As it approaches the sur- 
face, the skin becomes closely adherent to it, and changes its color 
gradually until it becomes deep purple. Unevenness and nodula- 
tion are seen, and very soon the skin begins to ulcerate, and be- 
fore long a foul, irregular, rough-edged fetid excavation occupies 
the outer part of the tumor. From the beginning there is a strong 
inelastic hardness to the sense of touch, as distinctive when atten- 
tively observed as almost any other symptom. This feature is 
not lost until ulceration is completely established. Another sense 

33 



514 DISEASES OF THE MAMM^ : 

is very forcibly impressed by a caneer in the ulcerative stage, viz., 
the smell. An ichor, formed of acrid serum, blood, pus, and mi- 
nute sloughs, yields a stench sufficient to render the patient loath- 
some to herself and others. The medullary form is never so very 
hard, but from the beginning often feels soft and so yielding to 
the touch, as to suggest the presence of fluid. The sense of fluc- 
tuation is always obscure enough to leave a doubt upon the mind 
of the observer. As it approaches the surface, the softness be- 
comes more marked ; points of prominence, generally more than 
one, sometimes several, are observed, pressing the skin upward, 
which becomes purple, and soon gives way. The disease rapidly 
bursts out into a bloody fungus, which springs above the surface, 
becoming detached in sloughs, and sending forth an excoriating 
fetid discharge, not unlike, but generally more copious, than the 
scirrhous variety. When the skin is attacked, the point first 
affected is likely to become more than ordinarily dense, and at- 
tached to the parts below, so as to give it a pinched appearance ; 
discoloration sooner or later occurs, and finally ulceration and 
rapid destruction of the parts. The nipple, if attacked, increases 
in size, becomes purple, cracks open, and disappears in sloughing 
ulceration. Very soon after, the parts immediately around the 
part first affected become implicated, the absorbents take up the 
malignant matter, and carrying it to the axillary glands, these 
become centres of disease, which slowly advances in the march of 
disintegration. The glands inside the chest become implicated in 
the same way, and at the same time. Distant parts in various por- 
tions of the system begin to degenerate, until not unfrequently 
the patient is affected in a multitude of parts, and the cancer be- 
comes a general disease. 

Whether these separate and distinct deposits are the effect of 
transmission and lodgements of cancerous matter, is more than our 
science has determined; some pathologists think so, while others 
believe that it is primarily a blood disease, and that the first as 
well as the last deposits or growths are the results of it. 

The constitutional symptoms vary with the stage and extent of 
the disease, and the constitutional condition of the patient. My 
experience, of course, will not compare with many who have writ- 
ten upon the subject ; but I am led to believe, from observation, 
that a large majority of patients are robust persons when the can- 



CANCER. 515 

cerous growth is discovered. In some of my cases this is a re- 
markable feature ; the patients seemed to enjoy excellent health, 
and suffered from no sort of inconvenience, much less cachexia. 
The fact of the breast being on a very exposed part of the person, 
a part which frequently comes under the eye and hand of the pa- 
tient, would lead to an early discovery of disease in it, than would 
take place when it is situated in the internal organs. This will 
account for the fact, that recognized cases of cancer of the breast 
are not always, from the beginning, connected with a cachectic con- 
dition of the system ; while the cachexia is manifested before we 
discover the cancer in the uterus or other internal organs. 

I have been induced to infer from authors, that cancerous ca- 
chexia was a precedent circumstance to the development of local 
carcinoma ; while my own observation has driven me to the belief 
that it is but a symptom of the advanced condition of that affec- 
tion. 

The peculiar straw-colored translucency of the surface in can- 
cerous patients, does not, as a general thing, appear obvious until 
the growth is large enough, and the deposits numerous enough to 
influence hsematosis, as a like amount of disease of a benignant 
nature would do. It sometimes is induced by the exhausting in- 
fluence of cancerous discharges, the watchful restlessness, and 
disturbances of digestion and nutrition. It is merely the result 
of blood depravity and poverty, and may be classed in the same 
category with anaemia. We may be prepared, therefore, to find 
cancerous growths without cachexia, but we also see cancer com- 
mencing in broken-down constitutions; but I think we ought not 
to attach undue importance to this fact. 

Entertaining this view of the connection between constitutional 
and local symptoms, it is not necessary to describe with minute- 
ness the establishment and progress of the cachectic declivity down 
which the patient glides to her final home. The symptoms are 
much the same as cachectic suffering from any protracted disease. 

Diagnosis. — The diagnosis of cancer of the breast is not gen- 
erally difficult, as its characteristics, for the most part, are strongly 
marked ; but sometimes there is great doubt whether, in a given 
case, the patient is laboring under malignant or benign disease. I 
need not say that the distinction is a subject of very great impor- 
tance. Tumors of other character than cancerous may so much 



516 DISEASES OF THE MAMMJ : 

resemble this, and the converse, that it may be well to mention 
and contrast the differences in this connection. 

Malignant growths are rapid ; benign, slow. Malignant growths 
occur in patients over thirty-five generally, and most frequently 
in childbearing women ; while benign tumors grow in persons who 
are single or sterile, and under thirty-five years of age. 

Carcinoma is painful, but not tender; benignant tumors are 
neither painful nor tender. The former contract adhesions readily 
and early, while the latter are always moved with facility. Ma- 
lignant tumors are often irregular and knotty, but not lobular ; 
while the adenoid tumor has a regular lobulated feel, that by care 
may be almost always verified. In cancer, the nipple is very soon 
retracted ; while in the non-malignant, retraction does not take 
place, or at least very seldom. Chronic inflammation begins during 
lactation, in persons under forty, is usually, if not always tender, 
and has none of the lancinating pains of carcinoma , is not so 
stony hard as scirrhus, before suppuration, nor so soft as the en- 
cephaloid variety, and is generally more extensive than cancer in 
the very beginning, and more regularly developed. 

The diagnosis of cancer after ulceration is not difficult. The 
sharp irregular projecting edges, the uneven surface, the very 
large stony granulations, and the foul ichorous discharge, with the 
fetid, intolerable smell, are unmistakable characteristics. The fun- 
gous or encephaloid, in its open condition, is not similar to any- 
thing else with which I am acquainted. It grows with almost ex- 
plosive energy ; in a few months from the beginning, the part is 
very large. The surface, uneven, nodulated, and purple, feels firm 
in some places, in others soft enough to contain fluid. The skin 
soon gives way, and large, red, bleeding, suppurating, sloughing 
fungi shoot through it, and shed upon the surrounding parts an 
acrid, excoriating, fetid ichor, that irritates everything it touches. 
The fungus spreads and sloughs, and bleeds and smells, as nothing 
else on a living being can. There is no danger of confounding it 
with anything beside. 

When any doubts exist as to the diagnosis between this variety 
of cancer and chronic inflammation in the suppurative stage of the 
one, and the subcutaneous growth of the other, the exploring 
needle will demonstrate the difference. 

Prognosis, — The almost invariable fatal termination of carci- 



CANCER. 517 

noma, under every variety of management as yet within the possi- 
bility of our profession, paralyzes every hope of the patient when 
she learns the nature of her disease, and discourages resort to 
radical measures, only in exceptional cases. It is fatal with treat- 
ment, and without it. Its duration, compared with other chronic 
diseases, is short. This is particularly the case with the encepha- 
loid variety. The younger the patient, the more rapidly it marches 
through its different stages to dissolution. From nine months to 
three years are the limits, or nearly so, of its duration. One 
reason why it terminates more rapidly in young persons is, that 
scirrhus does not often occur in the young, while the fungous va- 
riety occurs much more frequently. 

Causes. — Very little is known of the causes of cancer. It is 
believed to be hereditary in certain families, and perhaps this in- 
fluence has as much effect in bringing it about as any other ; but 
I think the veil thus used to cover our ignorance should be lifted, 
by the manly acknowledgment of our want of knowledge. In- 
stances occur that are attributed by the patient to a blow or bruise ; 
but this is more likely a coincidence than a cause. In fact, I think 
we know nothing of the etiology of cancer, although many circum- 
stances under which it occurs are well determined. 

It is to be hoped that, at no very distant day, the numerous and 
effective means of research so successfully brought to bear upon 
other obscure subjects, will result in a definite settlement of the 
question, What are the causes of cancer, and what the cure ? It 
is not too much to believe that such will be the case. 

Treatment. — Notwithstanding the hopelessness of treatment in 
cancer, so far as the general result is concerned, much may be done 
to palliate the sufferings through which our patient must inevita- 
bly pass, and some hope is yet indulged that life may be some- 
what protracted. It is not my purpose to argue the propriety or 
impropriety of pursuing a given course, but succinctly to give my 
convictions in the several items of treatment I shall present. In 
the early stages there is not much indication for general or consti- 
tutional remedies, as the health of the patient is not much, if at 
all, deteriorated ; but, as its ravages make inroads upon the func- 
tion of nutrition, nutritious diet and bracing regimen, with medi- 
cinal tonics, will do a great deal towards postponing the fatal 
prostration. Of the tonics, the preparations of iron are, perhaps, 



518 DISEASES OF THE MAMMJ1: 

the best, and yet we often increase their efficacy by the co-ordi- 
nate employment of the bitters. The latter are used to influence 
the stomach under digestion ; the former to promote hgematosis. 
There is no specific for cancer ; nothing that will contend with 
its eccentric cell-formations and destroy them. We must promote 
the healthy discharge of the important functions, and preserve as 
far as possible the integrity of the vital organs. To do this best 
we must watch their aberration, and treat them upon general prin- 
ciples. After the disease has advanced to a certain degree, the 
all-absorbing symptoms are connected with the nervous system ; 
the patient suffers excruciating pain, is annoyed by sleepless 
nights, nervousness, and depression of spirits. A well-directed 
use of anodynes will afford the patient great relief from all these 
symptoms, and ease her to the grave. And the physician should 
remember that the profession and humanity demand of him all the 
ingenuity and skill he is capable of exercising to fulfil these ob- 
jects in the completest manner. Opium is, of course, the great 
solace of the patient ; and while it should not be doled out so nig- 
gardly as to fall short of great relief, it ought not to be so lavishly 
given as to arrest digestion, or destroy its usefulness by overdoses. 
With some patients the different preparations of alcohol are equally 
effective in the relief of pain. In such cases an alternation of 
them with opium will preserve the patient in a better state of gen- 
eral health than either alone. The anodyne may be made to do 
some good by local application, particularly subcutaneous injec- 
tions of morphia. To sprinkle the powder of morphia upon the 
ulcerated surface, or wash the part and keep in contact with it a 
watery solution of the aqueous extract of opium in lint, saturated 
with the solution, will be often effective. 

There is, perhaps, no radical cure for cancer of any kind ; and 
yet we are sometimes justifiable in taking what in other cases are 
usually regarded as radical measures. I have seen some cases of 
cancer of the breast amputated with what seemed to me to be the 
prolongation of the patient's life, and hence I do not hesitate, in 
a case where the development is slow, where there is no discolora- 
tion of the skin, and when the maxillary or other lymphatic gan- 
glions, so far as we may be able to determine, are not implicated, 
and the patient is in good general health, to amputate the diseased 



CANCER. 519 

gland. When any of the visible parts are affected, the skinj the 
ganglions, or other tissues, amputation will not even prolong life. 

It may be very properly said that the case I describe as suitable 
for amputation is the kind of case that the patient -will live longest 
under, and the worst to determine the worth of that operation, — 
and that is true. I may be also wrong in thus directing amputa- 
tion, but they are certainly the only cases in which ablation has 
seemed to me to be beneficial. As to the mode of removing the 
breast, I am decidedly in favor of the knife, but must freely ac- 
knowledge that my experience is very limited in the use of caus- 
tics, never having seen, I believe, but two thus removed. 



CHAPTER XXX. \S 

PUEKPEEAL CONVULSIONS. 

Pressure of the gravid uterus within the abdomen seems to be 
the originating cause of this kind of convulsions, for although there 
may be cases of ursemic convulsions arising to some extent in the 
same state of the blood and nervous system as in Bright' s disease, 
and perhaps others, the chain of pathological changes originates as 
the effect of some other causes ; while in the pregnant condition 
they are so unfrequently operative as scarcely to be worth serious 
consideration. 

As the uterus increases in size within the pelvis, it presses upon 
the rectum and bladder, especially the first, preventing the free and 
easy evacuation of the faeces, thus giving rise to such a loaded state 
of the alimentary canal as to cause it to occupy a larger space in 
the abdomen than usual. This pressure upon the rectum is what 
perhaps causes the general gaseous distension of the abdomen in 
the first few weeks of pregnancy. As it rises higher and occupies 
more room, the veins passing through and along the brim of the 
pelvis are pressed upon, so that the labia, perineum, and lower ex- 
tremities, become unusually filled with venous blood ; and after 
pregnancy is further advanced, this stagnation goes so far that 
serum is pressed out of the capillary extremities of the veins into 
the areolar tissue, causing oedematous tumefaction of the parts. 
The legs and labia swell quite largely in many cases. The veins 
themselves become greatly distended, their calibre is increased, 
and sometimes their walls give way, large varices are formed, and 
in rare instances rupture takes place. The blood thus long detained 
and so slowly returned into the general circulation must undergo 
excessive venusation. The venous changes in the blood must be 
excessive compared to what they would be if that fluid flowed with 
its wonted rapidity, and probably deteriorated in quality by the 
detention, either destroying or impairing some of its ordinary ele- 
ments, or impregnating it with deleterious materials. 



PUERPERAL CONVULSIONS. 521 

Increasing still more in size, the uterus comes to press upon the 
iliac and aortic arteries, preventing the blood from reaching the 
lower extremities in the usual quantities, and by the backward 
pressure thus made upon the column of blood causes more of it to 
be sent to the upper part of the body and head. This upward dis- 
tribution of the blood is augmented by the pressure exerted upon 
the small arteries and capillaries in the abdomen, excluding it to 
a considerable degree from this cavity when distension becomes 
great. From these two conditions arises a true hyperemia of the 
head, and consequent increased general excitability. Whether the 
spinal cord partakes of this state, I am not aware, but it most 
likely does. The diaphragm is pushed up further into the chest 
than usual, the cavity of the thorax is thus very materially dimin- 
ished, and consequently contains less blood than ordinary. After 
looking at these effects of pressure upon the systemic and pul- 
monary circulation, no one can be surprised at the hypersemic ex- 
citability so frequently observed in the last weeks of pregnancy. 
But pressure upon the abdominal organs not only causes unequal 
distribution of the blood, but deteriorates its composition. The 
excretory and secretory capacity of the organs is impaired. The 
mucous crypts and intestinal glands do not produce their full sup- 
ply of secretion, nor is the watery exudation from the mucous 
membrane as great as usual; the faeces become dry as a conse- 
quence, and pressure upon the sigmoid flexure of the colon and the 
rectum adds all that is necessary to bring about constipation more 
or less obstinate. The liver and pancreas are doubtless likewise 
prevented in the same way from pouring their stimulating fluids 
into the alimentary canal as plentifully as common. 

Another and more deleterious concatenation of circumstances be- 
gins in the pressure upon the emulgent veins and substance of the 
kidneys. Pressure upon the emulgent veins retards the return of 
blood from the kidneys to the general circulation, the capillaries 
are over-distended with blood until some of the serum of that fluid 
transudes their sides and appears in the urine, and when the urine 
is properly tested the albumen thus effused is detected in it. 
This exudation is in itself a matter of minor importance, otherwise 
than as an indication and evidence of embarrassment in the excre- 
tory function of the kidneys. The passive or venous hyperemia 
which exists when albumen is discoverable in the urine, is sufficient 



522 PUERPERAL CONVULSIONS. 

to prevent the excretion of urea. Generally, therefore, the urine 
that contains albumen in considerable quantities is deficient in 
urea. The azotic elements of this excretion are retained in the 
blood, and may be detected by chemical reagents, according to 
some observers, in the form of carb. of ammonia. We are, I think, 
yet hardly warranted, however, in deciding the precise form they 
assume after failing to find their way out of the blood, but ample 
observation attests their deleterious effects upon the nervous cen- 
tres, both animal and vital. The palpitation of the heart and sus- 
ceptibility of the stomach to irritant influences, show how the great 
sympathetic plexuses are affected by it; while the abnormal sensa- 
tions and movements, the neuralgic pains, convulsions, &c, de- 
monstrate the deleterious action exerted upon the brain and spinal 
cord. Although convulsions occur in all kinds of patients suffer- 
ing from albuminuria, yet their frequency and urgency are beyond 
all comparison greater in puerperal patients. This, no doubt, 
arises from the fact that in ordinary Bright's disease, the albumi- 
nuria of children in eruptive diseases, &c, &c, there is not that 
hyperaemic state r of the nervous centres caused by pressure upon 
the large arteries, and abdominal and thoracic organs, that there 
is in puerperal women. The coincidence of uraemia and cerebral 
hyperemia constitutes the peculiarity of the latter class of patients, 
both exalting the excitability of the nervous centres ; the hyper- 
emia furnishing an unusually high nutrition to the nerve-cells, 
thereby making the changes in them more easy and rapid, the 
uraemia by a direct stimulating influence upon them by contact. 
This conjectural explanation may not be correct; the main facts 
nevertheless of cerebral hyperaemia, uraemia, and puerperal con- 
vulsions, probably, almost if not quite always, go together. 

This is too short a sketch of the effects of pressure of the gravid 
uterus to contain everything relating to it. The remarks are in- 
tended more as suggestive than as full explanations. I cannot 
forbear,, however, in this connection, from alluding to the theory 
of anaemia as contrasted with the plethora of pregnancy. I think 
the weight of authority is in favor of the idea that most women — 
certainly not all — are rendered somewhat anaemic by pregnancy. 
Considering the great pressure upon the abdominal organs, how it 
would prevent perfect chylification and lacteal absorption, we at 
least have something of an explanation of the manner of its occur- 



PUERPERAL CONVULSIONS. 523 

rence. It should be borne in mind, in connection with the above 
explanation of the predisposing conditions — for they are usually 
only predisposing circumstances, many patients having them all 
without being convulsed — that the pressure is effective in the pro- 
duction of them only in patients whose abdominal muscles are rigid 
and comparatively unyielding, not permitting the uterus to distend 
them much, but keeping it pressed tightly against the posterior 
wall of the abdomen. The large vessels are, thus pressed against 
the spinal column. Primiparae present this state of the abdominal 
muscles more frequently than any other kinds of patients, and the 
older the primipara, generally the more rigid the muscles are. 
And we find that convulsions occur much more frequently— eighty 
per cent, of the cases — in patients pregnant with the first child. 
The pressure of the uterus in the abdomen is greatest during preg- 
nancy about the end of the eighth month, and fore part of the 
ninth. I have seen more cases of convulsions about this time than 
any other. It will be recollected, that during the ninth month the 
organ settles down lower into the pelvis, presses more upon the 
veins of the lower extremities, and less upon the great arteries and 
abdominal organs. The convulsions may take place as early as 
the sixth month. I knew one fatal case at this period of preg- 
nancy. They frequently occur during labor, and after it less often. 
The conditions above may be present in sufficient intensity to cause 
convulsions, though I think there is almost always present some ex- 
citing cause proper. They may be regarded as predisposing in their 
effects usually, and speaking in the language of Marshall Hall, we 
may call them centric, because they affect the nervous centres di- 
rectly. Most other causes are excentric, and affect the nervous 
centres indirectly, and excite them to the production of convulsive 
movements in the muscles. Perhaps the most common of these 
last is labor, the pains of which, operating in a reflex manner upon 
the brain and spinal nervous centres, wrought up to an unusual sus- 
ceptibility by the hyperemia and uraemia, caused by uterine pres- 
sure, are sufficient to induce convulsions. Gastric, intestinal, and 
cervical irritation have a similar influence. In the same way the 
pressure of the foetal head upon the cervix uteri, vaginal walls, sa- 
cral plexus of nerves, perineum, external organs, &c, &c. Any 
circumstance that causes unusual pain or local nervous excitement 
may, by reflex effects upon the spinal centres, corresponding to the 



524 PUERPERAL CONVULSIONS. 

affected locality, set up a chain of phenomena that will result in a 
convulsive paroxysm. The emotions or passions, fright, the effect 
of bright light, loud noises, all these, and many others, are not 
unfrequently sufficient exciting causes. I think that but very few 
persons are so susceptible by reason of the delicacy or susceptibility 
of their natural organisation as to be thrown into convulsions by 
any of the causes here enumerated as exciting, and believe they 
must be preceded by some such morbific influence as very much 
exalts the irritability of the general organism. I cannot, there- 
fore, subscribe to the doctrine of the sufficiency of these reflex 
causes alone. 

There can hardly be said to be any distinctive morbid anatomy 
of puerperal convulsions. The fatal conditions are often evanes- 
cent or inscrutable. In some instances there is much cerebral 
congestion, and very rarely sanguineous extravasation in the brain. 
More frequently there is serous effusion between the membranes 
or in the sinuses. Still more common is oedema of the areolar or 
interstitial tissue of the brain observed. The lungs are pretty 
constantly filled with oedematous appearances, and the air-cells 
and small bronchi gorged with tough mucus; sometimes great 
sanguineous congestion colors their structure extensively, while 
there is sometimes subserous emphysema. Probably as often as 
any other way the lungs and brain betray no evidence of violent 
action within them. I think it ought to be well understood, 
that these anatomical changes are the effects and not the causes 
of the convulsions. They are doubtless the causes of death in 
very many, if not all the cases in which they are observed, but I 
know of no well-informed pathologist of the present day who be- 
lieves them to be primary links in the chain of morbid states in 
the body. As I shall have occasion to explain hereafter, the con- 
vulsive paroxysms overwhelm these vital organs, by projecting the 
blood into them with great force, and preventing its return from 
them through the veins. 

The kidneys are more constantly and obviously affected, per- 
haps, than any other organ, and yet sometimes when uraemia has 
been an indubitable fact, they exhibit scarcely any appearance 
of disease. Ordinarily they are merely injected with an unusual 
amount of blood, the venous capillaries are more distended, and 
the cortical substance mottled less frequently than is, serous*, fibrin- 



PUERPERAL CONVULSIONS. 525 

ous, or even sanguineous effusion in the areolar tissue. It is not 
often the case that actual degeneration takes place ; very generally 
there is nothing more than vascular turgescence, which readily 
passes off when recovery takes place, and disappears as an effect 
of the post-mortem distribution of the blood. The uriniferous 
tubules sometimes contain albuminous casts and clots. 

Syynptoms. — The first thing that attracts our attention in preg- 
nant women, and leads us to suspect uraemia, is oedema. When 
this symptom is confined to the lower extremities it has not much 
significance, merely indicating pressure upon the venous trunks 
leading through the pelvis from below ; but when, with or without 
this, there is dropsical puffiness of the hands, face, arms, cellular 
tissue over the chest, hips, back, or any other portion of the upper 
parts of the person, we ought at once to suspect that the peculiar 
thin condition of the blood is caused by a loss of albumen. The 
oedema of uraemia, or rather albuminuria, in pregnancy, is not 
often either general or excessive. The hands become swollen more 
than ordinary, or the face. Sometimes the extent of the oedema 
is small, and it makes its appearance in one place for a short time, 
subsides, and appears in another. We may, for instance, find 
cases where, a part of the day, one side of the face swells up, and 
another part of the day one arm, and the face is relieved. With 
this symptom the patient is ordinarily unusually nervous. She 
has disturbed and dreamy sleep, startings and twitchings, neural- 
gic pains, headache, &c. There is often, too, indigestion, pain in 
the stomach, vomiting, and more or less febrile disturbance, pain 
in the loins, mental depression, and sometimes mental hallucina- 
tions. The bowels are constipated, the skin torpid, and the secre- 
tion of urine scanty and high-colored. The tongue is loaded with 
a whitish-yellow coating, the saliva abundant and offensive, causing 
almost a constant bad taste in the mouth, and disgust for food. 
Although these symptoms are pretty uniformly present, and suffi- 
ciently prominent to excite the attention of the patient and phy- 
sician, yet there are instances in which they are so slight as not 
to attract notice. I think the oedema will scarcely ever fail to 
show itself. Since my attention has been turned to the fact, I 
have not known convulsions to occur without it. The measure of 
its extent and duration has but little to do with the intensity and 
duration of the attack. It often occurs without convulsions, and 



526 PUERPERAL CONVULSIONS. 

it should be remembered that the quantity of effusion is only a 
measure of the extent of attenuation and not intoxication of the 
blood. Other causes may so deteriorate the process of hsematosis 
as to thin the blood very materially, while the function of the 
kidneys is not much if any disturbed, when this symptom will be 
greater in proportion than the results. All this is intended to show 
that although an invaluable, it is not an infallible symptom, indi- 
cating the presence of uraemia. 

. If the urine is tested in these cases, it will be found holding 
albumen in solution, and the relative quantity of albumen will 
indicate with some degree of accuracy the imminence of danger 
of an attack. An error in this respect may be very readily com- 
mitted by examining the urine voided at different times in the 
day. The first in the morning is apt to be the richest in quantity. 
The more fluid the patient takes, the more dilute the solution. 
Perhaps, upon the whole, the best way is to save the whole amount 
discharged for twenty-four hours and test portions of this as a 
whole. How long these premonitory symptoms precede the con- 
vulsive attack depends upon a great variety of circumstances, many 
of which are entirely inappreciable, and vary in duration from a 
few days to several weeks. 

The paroxysm is sometimes preceded, for some hours or but a 
few moments, by more marked and obvious phenomena. One pa- 
tient whom I attended saw a bright light for several minutes before 
the first paroxysm, and described its peculiarities. Blindness is 
often complained of. Double vision, half vision, intolerance of 
light, deafness, great sensitiveness to sound, and various versatile 
delusions, not unfrequently precede the convulsions. Unusual 
motions of one extremity, or numbness of it, a rolling or inability 
to direct the movement of the eyes, and occasionally an aura not 
unlike epileptic warning, begins in some part, and spreads towards 
the head or epigastrium. At other times the paroxysm bursts 
upon the victim with a suddenness as unexpected as alarming to 
the attendants. In whatever manner it may be initiated, the first 
general condition is that of great muscular tension; the head is 
slowly drawn back, and often to one side, the eyes and mouth are 
opened widely, the hands are clenched and drawn closely and 
forcibly up against the chest, the legs are stretched straight down- 
wards or slightly backwards, the feet are extended until almost 



PUERPERAL CONVULSIONS. 527 

upon a line with the limbs, the muscles of the abdomen, chest, 
and back, become rigid, and generally extend the body somewhat 
backwards. This general rigid condition of the muscles is main- 
tained for a few seconds, during which time the tongue is protruded 
beyond the teeth, sometimes projected very much, the eyes are 
closed, and the jaws brought together suddenly, wounding the 
tongue; the muscles of the face and extremities suddenly relax, 
and as suddenly contract so repeatedly, that convulsive contortions 
of the face present every phase of ludicrous grimace, while the 
limbs and back heave and throw the body about in every direction, 
and cause it to writhe and contort in every conceivable manner. 
One remarkable feature distinguishing this and other epileptic 
convulsions from most other forms of irregular muscular move- 
ments is, that the motion is symmetrical and synchronous in the 
two halves of the body. The two arms are moved in the same 
manner at the same time; the two legs, the two sides of the face, 
keep time and measure with each other. As the paroxysm draws 
to a close, the period of relaxation becomes longer, and the length 
of duration of the contraction shorter, until the relaxation is com- 
plete and universal, when the whole body and limbs assume a 
posture of helpless and unconscious repose. Although this re- 
laxation in most instances is confined to the voluntary muscles, 
sometimes the sphincters relax, and the urine and faeces escape 
from their receptacles without the knowledge of the patient. Dur- 
ing the early part of the paroxysm, the air is expelled from the 
lungs with great force until the chest is as nearly as possible 
empty of it ; and during the whole of the convulsion, there is but 
very little air admitted, sometimes none at all. At the conclusion, 
and with general relaxation, the rigidity of the thoracic and ab- 
dominal muscles gives way, and allows the air to enter into the 
lungs rapidly and in large quantities. The large amount of air thus 
admitted during the deep inspiration is expelled with a hissing noise 
through the teeth and mouth partly or wholly closed, sending the 
saliva, generally colored with blood, which flows from the wounded 
tongue, copiously over the person of the patient and the bed. 
This sibilant and deep respiration continues for a time, and gradu- 
ally gives place to more calm, and, after a while, natural breath- 
ing. A circumstance of great interest to the observer is the 
change of color noticed in the face, so obvious during the parox- 



528 PUERPERAL CONVULSIONS. 

ysm. At the commencemynt of the paroxysm, the face is natural 
in color, or perhaps pale ; during the fit it becomes turgid with 
blood, and red in color ; soon the redness becomes dusky, after- 
wards crimson, and finally very dark purple. The color is greatest 
at the time of the solution of the paroxysm, and passes slowly 
off after the respiration becomes good. I need not inform the 
student that this change in color depends upon the highly carbon- 
ized state of the blood circulating in the capillaries of the skin; 
and we have but to reflect that the blood circulating in the nervous 
centres is in the same condition, to understand the cause of the 
solution of the paroxysm. The blood surcharged with carbon, 
circulating in the brain and spinal cord, induces a true carbonic 
anaesthesia, hence the entire relaxation of the muscles, and the 
coma that succeeds the paroxysm ; when the blood is decarbonized 
and re-oxygenated, the coma subsides, the irritability returns, and 
the paroxysm, after a greater or less length of time, is repeated. 
Marshall Hall tells us that the glottis is closed as the first step in 
all these epileptiform convulsions, and looks upon it as the initia- 
tory if not the causing condition of them. Whether this is the 
case or not, the state of the thoracic and abdominal muscles 
renders perfect respiration impracticable, and the cessation of 
respiration ought to be regarded as the method adopted by nature 
of resolving and shortening the paroxysms, and serves as a basis 
on which to found rational practice. The state of the pulse can- 
not be ascertained during a paroxysm, but after its subsidence it 
is generally slow. The duration of a paroxysm is from half a 
minute or a few seconds only to several minutes. The more vio- 
lent and universal the muscular action, the shorter the time of 
duration. 

This description of the phenomena of a convulsive fit is appli- 
cable to the first or few first only, for as they recur, some of the 
symptoms become more intense and somewhat changed in appear- 
ance. The color of the face is darker in the first few paroxysms, 
and the stupor is of very short duration. In fact, after the first 
paroxysm, it is more like perfect relaxation than stupor, the 
breathing is seldom stertorous, and hissing and spirting but a 
short time. After each convulsion, there is more and more marked 
torpor, until it becomes profound and prolonged coma. The pa- 
tient does not arouse to consciousness, the eyes become turgid and 



PUERPERAL CONVULSIONS. 529 

continue half open, the inferior maxilla falls and leaves the 
mouth wide open, the tongue is swollen until it seems to fill the 
mouth and falls back upon the glottis, and the whole face is swollen 
and injected. The respiratory murmur, at first clear and com- 
plete all over the chest, soon becomes masked by the moist rale, 
and after a time a coarse mucous rhonchus obscures all other 
sounds, the breathing is more rapid, the pulse accelerated, and the 
general powers more prostrate, until the respiration becomes gasp- 
ing, the pulse is very rapid, and the skin covered with copious thin 
perspiration, and the patient expires; or the coma is more pro- 
found, the pulse slower, and the extremities cold, respiration less 
frequent and perfect, until the patient, after a longer or shorter 
struggle, expires. In the intervals, at first, there is apt to be 
restlessness; even where the patient is unconscious, the reflex 
sensitiveness is quite marked ; the patient will move her limbs when 
touched, the features become distorted when the skin on the face 
is lightly brushed ; but after the convulsions have continued for 
some hours, this passes off, and there is no reflex sensitiveness 
perceptible. This inter paroxysmal coma is the result of cerebral 
congestion, and is very different from the anesthetic condition 
which resolves the paroxysm early in the case. As the case 
grows worse, the anesthesia runs into and is complicated with 
coma ; but the attentive observer will be able to see the difference 
throughout the whole progress of the disease. It is not difficult 
to understand how the coma and difficult respiration should result 
from the effects of the recurring paroxysms. The compression 
of the abdominal and thoracic cavities expels much blood from the 
capillaries of their tissues, and presses it into the larger venous 
trunks, and thence into the heart, from which, on account of its 
accelerated movements, the blood is impelled rapidly and in large 
quantities into the great arteries ; and, as much resistance is made 
to its entrance into the small arteries of these cavities, there is a 
larger quantity driven into the brain, which does not return through 
the veins into the chest so readily as usual, on account of constric- 
tion of these by the muscular tension. A temporary congestion 
of the brain is the effect, and after repeated and prolonged parox- 
ysms the congestion becomes permanent, and great effusion of the 
serum of blood is produced. The longer the paroxysms and the 
more frequent their recurrence, the more rapid and deleterious 

34 



530 PUERPERAL CONVULSIONS. 

this effect of them, until apoplectic congestion is set up, and so 
much damage is done to the brain, — and perhaps spinal cord, — 
that it fails in its functions. The lungs are very powerfully com- 
pressed during the convulsion, mucus accumulates in the bronchi, 
while the want of the ordinary sensitiveness of the mucous sur- 
faces prevents the inconvenience to the respiration from being 
observed by the reflex nervous centres. This accumulation aids 
in deteriorating the quality of the blood, and consequently under- 
mining the powers of the system. In all the fatal cases I have 
observed anything like closely, I have witnessed a distressing de- 
gree of dyspnoea from this cause, and could not resist the convic- 
tion that the fatal catastrophe was accelerated more by this than 
any other condition. 

The frequency of the paroxysms varies in different cases from 
a few moments of intervals to many hours, say twelve, and even 
twenty-four. Sometimes there is marked periodicity in their re- 
turn, — every half hour, every two hours, &c. &c. 

Generally, they are preceded in their return by restlessness and 
other evidences of pain. After the convulsions have continued 
for a certain length of time, if there is to be a favorable termina- 
tion, they cease. Sometimes they cease gradually, the intervals 
becoming longer and the severity less, until they entirely fail to 
return; but generally they come to a somewhat sudden termina- 
tion, the last paroxysm being as bad or even worse than any of 
its predecessors. However this may be, the patient is left in a 
state of insensibility which lasts a longer or a shorter time, ac- 
cording to the damage done to the brain. Consciousness usually 
returns slowly, the movements receiving intelligent direction, and 
having some purpose in their object ; sounds affect the patient, or 
she may be induced to move by touch or annoyance of any kind, 
until she opens her eyes and directs them in a semi-sentient manner, 
and then falls asleep. This gradual awakening becomes complete 
in ten or twelve hours, or it may be two or three days. I knew 
one patient to remain unconscious for six days, and yet completely 
recover. After the recovery is fully effected, the memory of all 
that occurred during one, and sometimes a number of days prior 
to the attack, is wholly obliterated. It is a blank in her existence. 

Puerperal convulsions are said to be followed quite frequently 
by some other form of puerperal disease. This is not in accord- 



PUERPERAL CONVULSIONS. 531 

ance with my observation. Indeed, I cannot now recall a case 
where the patient did not recover without further puerperal acci- 
dent or trouble. 

Uterine symptoms are not uniform ; sometimes there are none ; 
for so far as we can judge by examination of the uterus, and ob- 
servations of the manner of the patient or any complaint, labor in 
many cases does not commence before the convulsions. Rarely 
we meet with cases that recover from them and are not delivered 
for several weeks afterwards. The first case I ever saw, the pa- 
tient, after having convulsions for twenty-four hours, and ten or 
twelve in number, recovered perfectly, and in five weeks after- 
wards was delivered of a foetus that probably ceased to live at the 
time she had the convulsions. Where there are no uterine symp- 
toms at first, labor is apt to commence soon after the convulsions 
become severe, and proceed slowly to a termination, or advance 
so tardily as not to be complete before a fatal termination of the 
disease. Again, we often meet with cases where labor is in active 
progress before the convulsions commence. Where this last is the 
condition of things, labor is not generally retarded, although oc- 
casionally it is brought to a complete stop. The symptoms may 
show themselves in the second or third stage of labor, or even after 
the whole process is finished. I knew one patient seized with these 
convulsions on the third day after delivery. Attacks after labor 
are more likely to take place very soon — in a few minutes, or a 
very few hours at most. 

The diagnosis is not generally difficult after the affection is com- 
pletely formed. In a practical point of view, it is quite impor- 
tant to diagnosticate the predisposition to this form of disease, 
and proper care will generally enable us to perceive the tendency 
in this direction when well marked. With the nervous and gas- 
tric derangement described above, there is oedema of the upper 
portion of the body, upper extremities, or face. While oedema of 
the legs and feet is more frequently produced by pressure upon 
the veins coming from the lower extremities, this symptom occur- 
ring in the last months or weeks of pregnancy in the upper part 
of the body is generally the effect of albuminuria. When this 
form of oedema shows itself, the urine should be subjected to tests 
for albumen. Whether uremia is always present when there is 
albuminuria, and whether ursemia does not sometimes occur with- 



532 PUERPERAL CONVULSIONS. 

out albuminuria, are questions which have not been positively de- 
cided, so far as I know ; but we can, with sufficient assurance, re- 
gard it as an invariable rule, that albuminuria indicates uraemia. 
If albumen is found in the urine, we should prove by tests that 
there is or is not a deficiency of urea and uric acid in the secre- 
tion. These two facts would show a predisposition to puerperal 
convulsions. The diagnosis, then, of the predisposition is made 
out by the presence of oedema of the upper part of the body, face, 
and limbs, albumen in the urine, and a deficiency of urea and uric 
acid. After the attack has supervened, the diagnosis, for the 
most part, lies between epilepsy, apoplexy, hysterical and puerpe- 
ral convulsions. There may be other affections with which there 
is a possibility of confounding these convulsions. Epileptic con- 
vulsions very rarely occur under puerperal circumstances in epi- 
leptic patients, and when they do, the convulsive seizure is not 
repeated. Apoplexy is ushered in sometimes by convulsions of 
short duration, to which characteristic profound and prolonged 
coma succeed. The convulsions are not repeated, the patient does 
not soon become conscious as after the first paroxysm of puerperal 
convulsions, and there is almost constantly nausea and vomiting 
with apoplexy. When coma is of more than very temporary dura- 
tion, there is congestion of the brain, either as the result of the 
convulsions or as a primary condition ; hence, we have a combina- 
tion of apoplexy and uraemic convulsions as a not unfrequent 
thing. I think, however, that apoplexy, uncomplicated with urae- 
mia, is quite uncommon in the puerperal state. I remember to 
have seen only one instance. As I have endeavored to show, in 
speaking of symptoms, the supervention of this complication is, 
perhaps, the most frequent cause of death, and it is what must, if 
possible, be avoided. Hysterical convulsions are distinguishable 
from the uraemic by symptoms arising from an opposite state than 
those of apoplexy, constant consciousness, more or less complete, 
and want of coma properly speaking. In hysteric convulsions, 
the color of the face is not so deep, the paroxysm is not terminated 
by carbonic anaesthesia, which shows the existence of apnoea ; there 
is, in fact, almost no embarrassment to the function of respiration 
in hysteria, while there constantly is in puerperal convulsions. In 
hysteric convulsions, the muscular contractions are not completely 
symmetrical, but one arm will be acting violently and the other 



PUERPERAL CONVULSIONS. 533 

firmly fixed, and the legs do not move synchronously like shocks 
that succeed the first general contraction in uremic cases ; and I 
hope I may be permitted to say, that in hysteria the mental mani- 
festations are perversities of disposition instead of the real inebri- 
ety of the ursemie disease. We must remember that they may be 
complicated, so that in the beginning we may have hysterical 
symptoms, but these are soon obscured by those arising from con- 
gestion of the brain. Perhaps, as in the premonitory condition, 
the most important items in a clear diagnosis are albuminuria and 
oedema. Examinations of the urine should be made when practi- 
cable. 

Prognosis. — This has reference, 1st, to the safety of the mother, 
and 2d, that of the child. According to Braun, 30 per cent, of 
the cases, under ordinary circumstances, prove fatal to the mother. 
My own observation leads me to a more favorable prognosis, and 
in the practice of my friends and myself, I think 25 would be a 
large estimate of the mortality of uremic puerperal convulsions. 
The particular circumstances influencing the prognosis are various. 
One of the most important is the time of the attack; commencing 
before or in the early steps of labor makes the case more danger- 
ous than if it takes place later, for, according to Braun, the ac- 
complishment of labor causes a cessation of the convulsions in 37 
per cent, of the cases, their amelioration in 31 per cent, more, and 
that about 32 per cent, continue without change. There is less 
danger in post-partum cases than those commencing during labor. 
Cases in which the inter-paroxysmal coma is profound and per- 
sistent, or the breathing and pulse are very much accelerated, or 
where the bronchia seem filled with mucus, and sibilant rale is 
heard over a large part, or, as is often the case, the whole of the 
chest, the prognosis is. grave; as is also the case, should the con- 
vulsions recur frequently, less than every hour, or continue for a 
long time. Cerebral, pulmonary, and circulatory deviations are 
the guides to the prognosis. The nearer the breathing and pulse 
continue to the natural standard, the more favorable the prognosis; 
the greater their departure from it in any respect, the greater the 
danger. This statement needs but very little qualification. The 
mortality to the foetus, if I can judge from the cases that have 
come under my own observation, is greater than that to the mother. 
I think at least half of the children born during puerperal con- 



534 PUERPERAL CONVULSIONS. 

vulsions were dead. The cause of this great mortality among the 
children is not clearly agreed upon by the profession. Some think 
the convulsive action of the uterus cramps the circulation, causing 
asphyxia. The most likely cause, I think, is the uraemia. I have 
known two well-marked cases of uraemia where convulsions did 
not take place, but the foeti in both cases were dead-born. In 
most cases, so soon as the labor has terminated, and the convul- 
sions cease, the albuminuria passes rapidly away, all evidences of 
uraemic poison disappear, and the patient uninterruptedly conva- 
lesces. At other times, several weeks elapse before the excretion 
returns to its normal state, when the convalescence is interrupted 
by the occurrence of dropsical accumulations, causing death or tedi- 
ous recovery, or there may be waning or great nervous prostration 
and fever. Very rarely the damage done to the brain is so great 
as to leave some part of the body or limbs partially or wholly 
paralyzed, or bronchial or pneumonic inflammation may be estab- 
lished sometimes, and not readily subside. 

Treatment. — The treatment is very properly and naturally di- 
vided into the medical and obstetrical. 

Although possibly not the most important, it is most convenient 
to consider the medical treatment first. The application of treat- 
ment is modified by the time when instituted ; that is, either as 
preventive or curative. As I have endeavored to show, we may 
often determine the presence of a predisposition to puerperal con- 
vulsions quite conclusively some days, and even weeks, before the 
supervention of an attack ; and not unfrequently, by proper treat- 
ment, entirely avoid the development of them. 

The two main indications in the medical treatment are : First, 
the removal of hyperaemia of the brain and spinal nervous cen- 
tres ; and, second, removal of the uraemia. 

To overcome both these morbid conditions is very desirable but 
sometimes impracticable, yet we can generally entirely get rid of 
one of them and thus avoid the commencement or continuance of 
the paroxysms. 

We will often be able to accomplish, one of the indications of a 
cure by preventive measures, viz., to remove hyperaemia of the 
nervous centres. The means to accomplish this end are bleed- 
ing, the administration of cathartics, diaphoretics, and diuretics. 
When the patient is plethoric, with a red injected face, a full and 



PUERPERAL CONVULSIONS. 535 

slow pulse, bloodletting should be resorted to. We may bleed 
the patient until these conditions are removed or very much re- 
duced. I hope I may be allowed to remark that when the predis- 
position is certainly present, we are justified in using, nay the case 
demands energetic measures, and that we ought not to be deterred 
from the employment of them for fear of inducing premature de- 
livery, for really this would add to the chances of both the patient 
and foetus. And for fear of being misunderstood by the student, 
I will repeat the main items diagnostic of the predisposition, viz., 
oedema of the upper part of the body, face, or limbs, or all together, 
albumen in the urine, and the various nervous symptoms I have 
mentioned. When to these are added those of decided plethora, 
an active antiphlogistic medication is generally very beneficial. 
One decided venesection in the sitting posture, until approaching 
syncope is observed, will sometimes do much good and entirely 
avert the attack. But active catharsis is also attended with very 
satisfactory results. The compound powder of jalap is one of the 
best of cathartics at such times. It should be administered in suffi- 
ciently large doses to cause copious watery evacuations. Should 
the patient not be decidedly plethoric, we may, with propriety, 
omit the bleeding, but the cathartic should be given. This should 
in either case be succeeded by the wine of colchicum in decided 
doses every four or six hours, and at least once a day the patient 
should have a steam bath to cause free diaphoresis. 

At any stage of this treatment nervous suffering should be 
promptly relieved by opium. The Dover powder is a good form. 
Very often such treatment is followed by premature labor, and 
when such is the case the labor is much less apt to be attended by 
this dreadful complication. I think this plan is very much more 
appropriate than an immediate resort to the intentional induction 
of premature labor without first reducing the cerebral hyperemia. 
This cerebral hyperemia should be held up to us as affording one of 
the most valuable indications of treatment; very often its removal is 
sufficient to render a very threatening case safe. The preventive 
treatment I have recommended is not always followed by prema- 
ture labor, as this process may not take place at the end of 
terra. Sponge baths of acetic acid, friction with acetic acid, and 
acid drinks and medicines, may be used with the hope that they 



536 PUERPERAL CONVULSIONS. 

may enter the blood and neutralize the ureal accumulations in that 
fluid. 

During a Paroxysm. — The first thing that should be attended 
to during the paroxysms is to prevent the injury which so fre- 
quently results to the tongue. A large cork, or a soft pine stick, 
should be placed between the molar teeth on one side while the 
jaws are separated, and thus retained, until the convulsion ceases. 
We ought not to be betrayed by any excitement into the use of a 
spoon-handle or other metallic substance, lest damage may be done 
to the teeth. The clothing should be loosened, so that the neck, 
body, or limbs, may not be constricted by it. The throat must be 
made entirely naked when practicable, and we must observe that 
the violent and irregular movements do not twist the clothing 
about some part of the person to an injurious degree. The at- 
tendants ought not to restrain the movements of the patient too 
greatly; indeed, perfect freedom to the whole body should be 
allowed when it does not become clear that it will result in throw- 
ing the patient off the bed or bruising her person. It is very 
harmful, for instance, to take hold of the limbs and try to hold 
them still. The bed should be large and firm enough to bear the 
weight of the attendants, if necessary. Plenty of air should be 
admitted into the room, and the latter should not be too warm. 
The face may be sprinkled or washed with cold water. I have 
tried to interrupt the convulsions by dashing the face suddenly 
with ice-water, but have not seen any effect from it that was de- 
sirable. 

Inter-paroxysmal Treatment. — It is a matter of the greatest 
moment to prevent a recurrence of the paroxysms ; if this can be 
done we are almost sure of success. The fewer the convulsions 
the less the danger, should be an ever-present fact with us. It is 
the frequent repetition of them that produces the fatal effects 
upon the brain. By the judicious use of chloroform we may pre- 
vent them from returning in a great many instances, if not all of 
them. Dr. Braun, of Vienna, recommends us to give chloroform 
as soon as there is any sign of a supervening paroxysm, and con- 
tinue it until sound sleep is induced; but I am sure that to ad- 
minister it in this way we shall fail to get all the good effects from 
its use that are practicable, for in many instances the premonition 
is so short we will not prevent the convulsion. The only safe way, 



PUERPERAL CONVULSIONS. 537 

and the one I now practice and would strongly recommend, is to 
keep the patient under its influence all the time sufficient to pre- 
vent a manifestation of the premonitory symptoms. 

This direction may be followed by sitting by her constantly, 
and administering the anaesthetic about every ten minutes gene- 
rally, but sometimes it may be necessary to have a small amount 
mixed with the air inhaled constantly. The intention is to very 
much lessen, if not entirely subdue, all reflex excitability, and 
keep it controlled until the cause of the trouble, uterine pressure, 
can be removed. The effect of the chloroform is to remove, or 
rather to subdue, the explosive excitability of the nervous centres 
caused by the circulation through them of the urea, carbonate of 
ammonia, or whatever other exciting stimulant has resulted from 
the retention of substances that ought to have been excreted by 
the kidneys. It is not likely that the chloroform chemically neu- 
tralizes the poison in the blood, but that it renders it inoperative 
by producing a more powerful but antagonistic influence upon the 
brain and medulla. It is not at all directly curative, it only sus- 
pends the action of the mischievous agent until curative means 
may be made effective in removing the pathological conditions 
upon which the convulsions depend. And I must insist, in all 
cases of uragmic puerperal convulsions, where there is enough ex- 
citability to keep reproducing the paroxysms, chloroform is appli- 
cable and demanded, whether attended with a urgemic, paralytic, or 
even apoplectic state of the brain and spinal cord or not. It is 
precisely to control this morbid excitability of the nervous system 
that it is used ; and although I have been governed by this prin- 
ciple for several years, I have never seen any unpleasant effects 
from its use in convulsions. And whenever I had cause to regret 
anything of my management of this most excellent remedy, it 
was that I had been too sparing with it, that I had not kept my 
patient sufficiently under its influence. It would hardly seem 
necessary to say that it is entirely useless during a paroxysm, 
except in very rare instances, in which respiration continues, be- 
cause it cannot be inhaled, as respiration is suspended, and that it 
is injurious immediately after the paroxysms, while the face is 
livid with carbonated blood. We wait until the face loses this 
asphyxiated appearance, and the blood is again charged with its 
usual amount of oxygen. As soon as this state is brought about 



538 PUERPERAL CONVULSIONS. 

we give the chloroform continually, and maintain an anesthetic 
condition that will keep the patient entirely free from the convul- 
sions. She should never be allowed to come out of this state until 
delivered, if this can be done by any allowable means, even should 
it require twenty-four, thirty-six, or forty-eight hours. After she 
is delivered she may be treated generally without further use of 
chloroform, but if the convulsions recur we should resort to it 
at once, and keep it up until renal and intestinal secretion is fairly 
established. Keeping the patient thus constantly anaesthetized 
beyond the convulsion-point, we ought to institute curative meas- 
ures with as much energy and activity as possible. 

Bloodletting is one of the first things to be thought of. The 
intention in using it is to reduce or remove the cerebral hyperemia, 
by lessening the amount of blood and reducing the arterial and 
cardiac vis a tergo. To effect this we must take a large quantity 
compared to the amount for other conditions of the system. From 
twenty to forty ounces will be required in one or two operations. 
The pulse must be affected by it. Sometimes a convulsive parox- 
ysm occurs while the patient is bleeding ; this ought to be pre- 
vented by chloroform. I have several times bled patients under 
the influence of chloroform. The anesthesia should be slight 
during the bleeding, but sufficient to prevent the paroxysms, and 
the patient must be more closely watched. She should be sup- 
ported in a sitting posture while the blood is running, and as soon 
as the pulse becomes decidedly quicker, we should lay her down 
and stop the blood, and if necessary repeat it when reaction has 
resulted. One copious or two moderate bleedings is allowable 
almost always, and in very plethoric patients two or more copious 
bleedings. Those old worthies in the profession, Gooch, Arm- 
strong, and others of like stamp, cured many cases of puerperal 
convulsions by powerful depletory treatment alone. Gooch thought 
bleeding the remedy. As I have endeavored to show, the apoplectic 
congestion of the brain is an important item, although not, as was 
supposed by the older authors, the only item. It is probably of 
secondary importance, but its removal goes a great way towards a 
cure. I insist that bleeding is one of the very best curative meas- 
ures, and should be considered in all cases. At the same time that 
we bleed, or if we do not think best to institute bloodletting, we 
may, with great propriety, administer an active cathartic. And 



PUERPERAL CONVULSIONS. 539 

in doing so we are to remember that promptness is a necessary 
quality; for the longer the bleeding is delayed, and the longer the 
cathartic is in operating, the more valuable time is lost. 

If we can procure copious and early catharsis without pain, we 
make a very favorable impression. The medicine I have used most, 
and still continue to recommend, is croton oil. I usually admin- 
ister one drop in an emulsion every hour until it operates thor- 
oughly, which, if good, it will do after two or three doses. This 
treatment will seldom fail to very much modify the severity of the 
symptoms, and in very many instances completely arrest the con- 
vulsions. I know that before the days of chloroform, at a time 
when the pathology of these cases was not as well understood as 
now, twenty-five to thirty years ago, many were cured by this 
treatment; and I am cognizant of two cases in which the convul- 
sions were arrested, and delivery did not take place in one until 
three and the other five weeks afterwards, each patient carrying a 
dead child that long, and being- delivered without interference or 
further convulsions. We then bled in both arms in a full stream 
until there was a close approach to syncope, and sometimes twice, 
and even thrice, in the same case, and gave the croton oil cathartic 
at the time we bled. And with all deference and respect for those 
who have learned to do better without than with bleeding, I must 
assure the profession that such success as attended our efforts then 
would not put them to the blush now. I am afraid that the tendency 
now is to magnify to an undue extent the effects of uraemia, and 
depreciate the importance of cerebral hyperemia. And in saying 
this I feel assured that a proper estimate of uraemia will make it 
a very dangerous element of the disease, while I think I but ex- 
press the conviction of the most judicious and thinking portion of 
the profession, when I say that we have no remedy for it that acts 
with anything like the promptitude that those do which prove effec- 
tive in the cerebral congestion. That we may very much modify 
if not relieve, the latter, in a few hours, nay minutes, while the 
uraemia cannot be remedied in less than one or tivo days. After 
proper depletion, or with it, cold to the head, ice in bladders or 
India-rubber bags, will aid in the same thing, reducing cerebral 
congestion ; and opium administered in sedative doses may so 
affect the nervous centres as to materially lessen their violence ; it 
operates somewhat in the same manner that chloroform does by 



540 PUERPERAL CONVULSIONS. 

diminishing the excitability of these organs. It does not exert 
any curative power, it only holds the convulsions in abeyance 
until the uraemia and hyperemia are removed. Acids undoubtedly 
act beneficially by attacking the irritating compound circulating 
in the blood. We must not expect too much from them, however. 
Acetic and citric acid drinks, vinegar baths, acid compresses over 
the abdominal surface, back, &c, should be resorted to as much 
as in the nature of the case is practicable. Then we should resort 
to diuretics and hydragogues of a particular character. Colchicum, 
or its preparations, is a powerful diuretic, and has the reputation 
of inciting the kidneys to the secretion of urea. When given in 
large doses it proves a hydragogue cathartic and emetic. A tea- 
spoonful of the vinous tincture every hour, until perceptible effects 
result, and then continued in such doses as the patient can bear 
without great irritation in the alimentary canal, is the usual mode 
of using it here. Other diuretics would probably be useful. 

A very important part of the treatment is obstetrical. If the 
views above expressed are true, so long as the uterus maintains 
its extreme size, the pressure on the large vessels, and the vessels 
and substance of the kidneys, is continued, the evil-working cause 
is kept up; and while the subsidence of that organ in the pelvis 
and the consequent relief to the tension of the abdominal muscles, 
takes off some of this pressure, and sometimes this extends the 
critical period, if it does not entirely arrest it, yet it is not gene- 
rally sufficient, and the patient is not usually safe until it is 
emptied. 

The obstetrical treatment will vary somewhat, owing to the time 
when the convulsions occur. During pregnancy, any time before 
term, premature labor is apt to supervene as the effect of the con- 
vulsions or the condition of the system upon which they depend. 
And should this be the case it may be accelerated by means which 
I shall presently indicate; but if there are no signs of labor, the 
treatment should be wholly medical, and may be conducted as I 
have directed above. If labor has commenced and dilatation is 
slow and difficult, we should dilate the os by artificial means. 
The only one I have ever resorted to is the finger. By placing 
one or two fingers in the mouth of the uterus and gently but con- 
stantly keeping up pressure upon it from within outwards, we will 
very much shorten the stage of dilatation. The effort to dilate 



PUERPERAL CONVULSIONS. 541 

should not be abated during pain, nor in the intervals, but a con- 
stant fatiguing pressure made. So soon as the os is dilated to two 
inches in diameter, we ought to rupture the membranes and allow 
the liquor amnii to flow out. This will generally add energy to 
the contractions and somewhat lessen the size of the uterus. We 
should not desist from dilatation until the head has emerged from 
the cervix entirely. If the head is not readily expelled, we must 
apply the forceps and assist by judicious traction. If labor pro- 
ceeds, however, with reasonable activity, and we can succeed in 
controlling the convulsions, we must abstain from operative pro- 
cedure entirely. An indispensable condition in all cases where it 
is necessary to accelerate delivery by any means whatever, is to 
keep the patient deeply under the influence of chloroform, so much 
as is necessary to preclude the danger of additional irritation thus 
caused, bringing convulsions. To dilate, rupture the membranes, 
and use the forceps, should be the extent of our interference, un- 
less when the feet, knees, or breech presents. Where either of 
these parts can be seized, we may aid very materially by traction 
upon it. Craniotomy is not justifiable until we can demonstrate 
the death of the foetus, unless indicated by circumstances inde- 
pendent of the uraemia, such as disparity of size between the head 
and pelvis, or ineffectual efforts with the forceps. Neither are 
we to think of turning. In fact, we must do no more than is 
absolutely necessary, and do that in such a way as to cause the 
least possible irritation, and be sure to use chloroform liberally. I 
say that I have never used anything but my fingers to dilate the 
uterus, but there is a variety of very efficient means used for this 
purpose. The compressed sponge is one of the means very effi. 
cient, quite handy and available. Dr. Barnes's dilators are also 
very eligible and efficient. These consist of gum elastic air-bags 
of different sizes. The smallest should be introduced into the 
cervix empty, by means of the probe, and then inflated through a 
tube attached to it; in an hour this may be replaced by the next 
larger, and so on until the mouth is fully dilated. If the com- 
pressed sponge is used, a piece large enough to pass easily into 
the cavity of the cervix may be introduced, and in three hours a 
larger one if necessary, and so on until the process is completed. 
Convulsions commencing after labor is finished, necessitate an 
examination of the uterine globe externally and internally, by in- 



542 PUERPERAL CONVULSIONS. 

troducing the finger into its mouth, to see that the organ is well 
contracted, and there are no imprisoned clots that are causing 
irritation. If contraction is not good and blood coagula accumu- 
late, we may use friction above the pubes and give ergot enough 
to secure the desired effect. Depletion, cathartics, diuretics, and 
opium, with chloroform, are to constitute the treatment, as in the 
other condition above mentioned. 



CHAPTER XXXI. 

PHLEGMASIA ALBA DOLENS, OR CRURAL PHLEBITIS. 

Nature and Anatomy. — Inflammation of the uterine branches 
of the hypogastric vein, the hypogastric, iliac, and femoral vein, 
and, in some instances, the popliteal and lower branches of the 
veins of the lower extremities, seems to be the initiatory step in 
phlegmasia dolens. There is not merely inflammation of these 
veins, but they are also filled to a greater or less extent with 
coagula, of sufficient firmness to obstruct and even entirely inter- 
rupt the flow of blood through them. The blood returning from 
the extremity is thus crowded out of the principal channels, and 
made to seek the ascending vena cava through more circuitous 
routes and less commodious vessels, while the arteries correspond- 
ing to the occluded veins are acting with more than ordinary fre- 
quency, and with their natural capacity. The effect of this con- 
dition of the circulatory apparatus of the limb is to amass an 
unusual quantity of blood in the capillary vessels between the 
femoral artery and its branches, and the femoral vein and ramifi- 
cations, that can find its way out with difficulty. The walls of 
these minute tubes are thus distended to their utmost capacity, 
and are permeated by the thinner portion of the blood, — the se- 
rum, — which penetrates the inter and intra-muscular and subcuta- 
neous cellular tissue in every direction, thus producing enlargement 
of the limb by the accumulation of the watery elements of the 
blood. If the obstruction is complete, and the number of veins 
involved large, the extremity is enormously distended, and becomes 
hard and shining. 

Thus far the swollen limb is oedematous, and before excessive 
distension has been reached pits upon pressure. In the progress 
of the case, however, it becomes too firm to pit, and often remains 
stiff and hard for many months. The hardness is, doubtless, de- 
pendent upon coagulation of the fibrine contained in the serum as 



544 PHLEGMASIA ALBA DOLENS, OR CRURAL PHLEBITIS. 

it escapes from the vessels. This coagulation in the cellular tissue, 
within and around the muscles and beneath the skin, is somewhat 
permanent, and not reabsorbed perhaps entirely, in some cases, in 
the lifetime of the patient. She is, therefore, in future, more or 
less completely deprived of the use of the limb. There are very 
few cases in which the efficiency and usefulness of the member are 
not very much impaired for a long time. The fibrinous coagula- 
tion takes place generally in from four to fifteen days. When the 
effusion in the limb is not great, the hardness will not be very con- 
siderable ; but if excessive, the hardness and stiffness of the limb 
are correspondingly prominent circumstances. The veins, when 
dissected, show signs of decided inflammation in the thickening 
of their walls, deposition of layers of fibrine, and, after a time, in 
containing pus near the ends of the coagula. If the cellular sub- 
stance is cut into in the first few days, serum will be evacuated to 
such an extent as to decidedly lessen the size of the limb. Punc- 
tures may thus be made to relieve the painful distension attendant 
upon the early stages of the affection. After the fourteenth or 
fifteenth day, the punctures will still allow serum to escape, but 
not with the same facility, nor to a like extent, as before, and the 
limb will retain much of its firmness, however much it may be thus 
punctured. And if the tissue is cut into it will be found slightly 
firmer, and more dense than natural, showing adventitious sub- 
stance of a consistence greater than fluid. This, I think, is a fair 
exposition of the condition of the limb in phlegmasia do! ens, and 
from it most pathologists infer that inflammation of the veins is 
the beginning of the disease, coagulation in their cavity the second 
step, effusion of serum in the cellular tissue the third, and coagu- 
lation of the fibrine in the cells of the cellular tissue the fourth 
step. But some others, as McKinzie, Simpson, and others, think 
that behind all these is a peculiar condition of the blood that starts 
all the other phenomena into existence. Again, while Dr. Robert 
Lee, who has done more to elucidate this disease than any other 
one author, believes that the inflammation of the veins is the cause 
of the coagulation of the blood in them, Yirchow thinks that the 
coagula are the cause of the inflammation. The probability is, 
that while all the blood may not be diseased in the very beginnning, 
the absorption of the poison of decomposing substances in the 
uterus may so affect that part of it in the uterine branches of the 



ETIOLOGY. 545 

hypogastric vein as to start up inflammation in their walls, and, 
possibly, directly affect the blood in them, so as to promote the 
coagulability of it, and in that way begin the chain of phenomena. 
In the cases I have observed, offensiveness of the lochia was a very 
noticeable circumstance. The remarks I have made and shall make 
in reference to the character, cause, and treatment, are intended 
more particularly to apply to puerperal phlegmasia dolens, but I 
think they will also be, in the main, appropriate to the disease as 
it occurs under other circumstances and in the opposite sex. For 
we shall find, by investigating the subject extensively, that it is in 
nowise confined to the puerperal condition, the lower extremity, 
nor the female sex. 

Etiology. — Phlegmasia dolens occurs most frequently in women 
recently delivered, — the necessary inference from which is that 
there is something in this condition which predisposes to it. In 
what post-partum circumstance the predisposition consists, it would 
be difficult to say, but if we adopt the theory that the venous in- 
flammation begins in the uterine veins and spreads to others, the 
unusually enlarged state of the vessels, and greater accumulation 
of blood in and about the uterus, would afford sufficient reason for 
the susceptibility to morbific agencies. It will be rendered more 
likely that this is the rational mode of accounting for the predis- 
position in such cases, by the fact that an exciting or congestive 
influence exerted by cancer in the uterus, rectum, or vagina, the 
inflammation caused by the pressure, but more particularly the 
inflammation or disintegration, of uterine tumors, injuries of the 
pelvic organs in males or females, stricture of the urethra or 
wounding of this canal by the catheter, cancer of the rectum of 
the male or the male genital organs, or, in rare instances, of de- 
ranged menstruation, all act as predisposing causes of phlegmasia 
dolens. It is difficult to understand why these conditions should 
predispose to crural phlebitis, unless it is through the congestion 
they produce in the small veins which empty into the iliac or 
femoral vein. Disease, as suppurative inflammation in the axilla, 
or pressure upon the veins in that part, sometimes predisposes to 
phlebitis, and perhaps excites it, — that leads to phlegmasia dolens 
of the arm. It would seem that injuries done % to the uterus by 
turning, the use of instruments, or the rough management of the 
os in the first stage of labor, act as exciting causes. The absorp- 

35 



546 



tion of putrid matter from the uterus by the veins excites inflam- 
mation in the walls of the veins. The putrid matter may be re- 
tention of a portion or the whole of the placenta, which occurs 
sometimes in cases of abortion, retained membranes, or even blood 
at full term, &c. Outside causes, acting in conjunction with the 
internal predisposition, must also be enumerated as efficient excit- 
ing causes, as exposure to cold, too much exercise, too early re- 
sumption of the erect posture and ordinary business duties. The 
mind, doubtless, in some instances, has a powerful influence in in- 
ducing phlebitis of the extremity. Other causes not enumerated 
here may probably be influencing the patient to the assumption of 
this disease also. 

Symptoms and Progress. — Crural phlebitis may attack the 
lying-in woman any time from the fourth day after delivery to the 
end of the month or even later. I have a patient under treat- 
ment now, who was taken ill with phlegmasia dolens on the for- 
tieth day from the birth of her child. The most common time is 
within the first fourteen days. The onset is generally rather sud- 
den, accompanied with a chill, and succeeded by fever ; but often 
its commencement is not marked by any prominent symptom, and 
three or four days elapse before there is sufficient positiveness in 
its manifestations to enable us to discover the nature of the attack. 
The fever not unfrequently is the first symptom ; at others the 
pain precedes it; or again in some instances, the two begin consen- 
taneously. When fully formed, the extremity is swollen, hot, 
painful, and in some parts very tender to the touch. The swell- 
ing begins at various parts of the limb in different cases. It some- 
times begins in the upper part of the inside of the thigh, just below 
the groin; at others, it commences in the calf of the leg; and again 
in the popliteal region, and still, in other cases, in the foot. The 
tumefaction sometimes remains partial, not extending beyond the 
point of commencement. 

The case above referred to, is confined to the leg below the 
knee, with a small place on the inside of the thigh. Generally, 
however, — and this is particularly true of the cases occurring 
within the first ten days after delivery, — the swelling spreads from 
the places where it first shows itself all over the limb. The de- 
grees of distension are not constant, being sometimes so slight as 
to be merely easily recognized, while at others, the limb is in- 



SYMPTOMS AXD PROGRESS. 547 

creased to double its ordinary size. When the swelling is slight, 
the limb is soft ; but if the tumefaction is great, there is a pecu- 
liar hardness that prevents indentation without considerable force. 
In most cases in the beginning, pressure with the finger will pit 
the surface as in other kinds of oedema ; but as before remarked, 
pitting cannot be produced by pressure with the finger when the 
swelling is very great, and in all cases the enlarged part becomes 
harder after a few days. The swollen limb is not red, or other- 
wise discolored, it usually retaining its natural hue ; but in cases 
of excessive tumefaction, the skin becomes very white and shining. 
This white and shining aspect of the limb encouraged the use of, 
if it did not give origin to, the term "milk-leg," applied to it in 
ancient times. The swelling, when general, is equable, and seems 
to be governed in shape by the natural contour of the extremity. 
When, however, the swelling is partial, this is not the case ; and 
occasionally one part of the limb is tumefied and subsides, and 
some other part goes through the process, to be succeeded in these 
phenomena by still another part. The tumidity begins to subside, 
in the majority of instances, after twelve or fourteen days, and 
the subsidence is complete, or nearly so, at the end of from forty 
to ninety days; but in some cases the limb is not entirely relieved 
from swelling for several months, and in rare instances, the limb 
is not restored to its natural shape and size after the lapse of a 
long lifetime, it remaining swollen and stiff, and the veins en- 
larged. The effect upon the motion of the limb is various, also. 
The patient, in slight cases, can move the limb with great freedom, 
while in others, the least movement produces the most intense suf- 
fering. The suffering caused by movement seems to depend more 
on the pressure exercised upon the veins by the contracting mus- 
cles, than any tenderness in any other tissue in the limb ; and, in- 
deed, it will be found that any part not traversed by vein trunks, 
may be handled with impunity, but the moment the veins are 
pressed upon, there is suffering commensurate with the intensity 
of the inflammation in them. The pain is slight in less severe 
cases, but in the more intense the pain is often very severe, re- 
quiring the use of anodynes to secure rest at night. The pain 
begins most frequently, perhaps, in the groin, where in most of the 
cases there is hardness and tumefaction before elsewhere apparent. 
In others, and not unfrequently, it is first felt in the popliteal 



548 PHLEGMASIA ALBA DOLENS, OR CRURAL PHLEBITIS. 

space, and in still others in the ankle or foot. In slight cases, the 
pain is confined in one locality not unfrequently ; but we often 
meet with instances where the pain extends from one end of the 
extremity to the other. It will be observed generally, too, that 
the pain is in the locality of the inflamed veins, extending in lines 
corresponding with the course traversed by them. The veins may 
be usually traced throughout much of their course by their un- 
common hardness ; appearing like large round cords, which may 
be rolled under the finger, as well as by the pain and tenderness. 
The temperature of the aifected limb is generally higher than natu- 
ral, but in slight instances it is not changed, and, perhaps, even 
lower than ordinary. 

After the acute symptoms have subsided, the limb not unfre- 
quently remains large, stiff, and hard, impeding locomotion for a 
long time, and forever impairing the usefulness of the member. 

With these local symptoms we generally observe general ones 
of a febrile character, commencing, as before remarked, sometimes 
before and sometimes after the supervention of the local symp- 
toms. The temperature of the whole surface is increased, the 
pulse is more frequent than natural, sometimes hard and bounding, 
but generally less distinctly changed in any other respect than in 
frequency. The pulse is sometimes very frequent, varying from 
one hundred and twenty to one hundred and sixty in the minute. 
This is in a severe form of the affection, occurring soon after con- 
finement ; in less intense attacks the circulation is not so very 
much excited, and occasionally scarcely at all. The tongue is 
coated white at first, afterwards more dirty, and finally brown 
in some cases. Pain in the back, aching of the head, bones, of 
the extremities, &c, are the accompanying symptoms. The nerv- 
ous system sometimes partakes of the general morbid condition, 
when there is restlessness, sleeplessness, and delirium. The sto- 
mach enters into the circle of sympathetic derangement, so that 
we have loss of appetite, even nausea and vomiting, while the 
bowels are constipated, or affected with diarrhoea. In some cases, 
the lax condition of the bowels is a prominent and very trouble- 
some symptom. The lochia are not generally suppressed, although 
sometimes they are scanty, and at others, the disease does not 
make its appearance until after they have ceased to flow. This 



DIAGNOSIS — PROGNOSIS. 549 

discharge is usually fetid, or otherwise offensive, and occasionally 
so acrid as to produce abrasions on the external parts. 

The secretion of milk is almost uniformly influenced ; in bad 
cases it entirely ceases, while in very mild instances it is only 
rendered more than ordinarily scanty. 

Although phlegmasia dolens is usually confined to one limb, it 
has been occasionally observed in both at the same time. It very 
seldom invades the two limbs simultaneously, — first, almost run- 
ning its course in one, and then attacking the other, proceeding 
through its various steps to resolution or otherwise. 

Diagnosis. — It will not be necessary to draw a differential diag- 
nosis, as phlegmasia dolens is so distinctive in its history, rela- 
tions, symptoms, and physical appearance. When it occurs at 
other times than the puerperal state, and in the upper extremities, 
there may, for a time, be more reasons for doubt than usual. 
The oedema, confined to one extremity, with pain and soreness 
in the course of its principal veins, and the enlargement and 
hardened condition of them, feeling like cords under the finger, 
are sufficiently distinctive. 

Prognosis. — There are two items in the prognosis, — 1st, as to 
the recovery of the general health ; and, 2dly, the restoration of 
the usefulness of the limb involved in the disease. 

In a large majority of the cases we meet with in practice, the 
tendency is to resolution of the inflammation, the recovery from 
the general depressing influences of the acute attack, and the 
removal of the effusion from the textures of the limb, — in short, 
thorough recovery. 

The length of time in which these different conditions are re- 
moved, varies greatly in different cases. Most frequently, per- 
haps, the disease arrives at its acme in from fourteen to twenty- 
one days, when the pain, fever and swelling begin to subside : 
the pain first, the fever second, and lastly the swelling. In the 
course of from four to six weeks, the patient will be able to be up, 
and engage in some of her household duties ; but several months 
will elapse before the hardness, swelling, and stiffness of the leg, 
have entirely disappeared. This is favorable. Many instances are 
observed in which the patients are confined to their rooms, if not 
to their beds, for many months, and the limb is not restored for 
years, and sometimes never, but remains a misshaped mass of 



550 PHLEGMASIA ALBA DOLENS, OR CRURAL PHLEBITIS. 

fibrinous deposit, and deficient and impervious veins, rendering 
the patients cripples for all time to come in spite of the very best 
management. 

Treatment. — In robust patients, remembering that the disease 
is inflammatory, we should resort to antiphlogistic remedies early 
in the disease. If the inflammation in the veins can be checked 
or moderated so as to prevent their occlusion, the deposit in the 
limb may be prevented. I think I have seen the disease thus cut 
short in more than one instance by a tolerably energetic use of 
the antiphlogistic means. It will do but little if any good after 
the swelling in the lower part of the limb is fairly begun, to de- 
plete. The damage is already done, and we can do nothing more 
than palliate the symptoms, and remove the effects of the disease. 
Attention to the beginning of the case will often enable us to de- 
tect the swelling in .the groin, sometimes in the pelvis, and always 
in the upper and inner part of the thigh, before oedema of the lower 
part has begun. This is the time when we may derive invaluable 
service from energetic treatment. If the patient is quite strong, 
the pain severe, and the fever high, venesection to a degree ap- 
proaching syncope is, beyond all odds, the best step with which to 
begin the treatment ; and if the pain and tenderness of that part 
are not very much relieved in eighteen or twenty hours, from fif- 
teen to thirty leeches should be applied over the most painful part. 
Or if the patient is delicate, or the pain, swelling and fever less 
intense, the leeches may suffice without the venesection. The 
bleeding is to prevent, not to cure, the phlegmasia dolens, and is 
not to be thought of if there is much increase of size in the limb. 
We should, therefore, learn to detect the first pathological link in 
the chain of the phenomena, — inflammation of the veins. I think 
the dispute about the propriety of bleeding, either locally or gene- 
rally, has arisen and is perpetuated by forgetting or rather ignoring 
the fact that the swelling of the limb is not the inflammation but the 
consequence of it, and that not it, but the inflammation, can be bene- 
fited by the antiphlogistic treatment. Soon after, or even before 
bleeding or leeching, a dose of calomel and jalap, — ten grains of the 
former and fifteen of the latter, — should be given. After this has 
operated, and even before, we may begin to administer sedatives, 
diuretics, and diaphoretics. Two drops of tinct. verat. virid. every 
hour until the pulse is brought down to sixty or seventy per 



TREATMENT. 551 

minute, will be of great service. Much good may be done also by 
giving ten grains of the nitrate of potash every four or five hours. 
This treatment should be diligently and promptly applied until 
the disease is arrested, or the leg becomes distended from effusion, 
and then it must be abandoned for an alterative and anodyne 
course; or, as is almost always the case, we are not called until the 
swelling and oedema have become quite marked. The fever, if high, 
denoted by quick, sharp, or strong pulse, heat of surface, &c, 
after the limb has commenced to enlarge, is a reason for a mode- 
rate antiphlogistic course of treatment. In making the change or 
adapting the anodyne and alterative course, we must bear in mind 
that they are merely palliative. The alterative treatment should 
consist, in the first place, of gently but hardly perceptibly induc- 
ing the specific effects of mercury, and afterwards administering 
the iodide of potassium in decided doses. I usually give five or 
six grains in solution every four or five hours. The anodynes ought 
to be administered as sparingly as possible to enable the patient to 
rest with any comfort. At first, Dover's powder at bedtime, or 
in the daytime, when the sufferings are very great. Opium in 
some form, or its alkaloids, is the only kind of anodyne that may 
be depended upon. The bowels ought to be kept in a soluble state 
by laxatives. Cream of tartar as a drink, or citrate of magnesia 
in wineglassful doses every four or five hours, will generally answer. 
After the lapse of sufficient time to produce debility, tonics must 
be added to other general treatment. Quinia, in good, liberal 
doses, say two grains every four or six hours, some wine or malt 
liquors, and generous diet, as the gravity and chronicity of the 
attack seem to demand, will be indispensable. I am partial to the 
tinct. ferri. chl. It may be given in doses of twenty drops every 
six hours, and, in many cases, is a very valuable tonic and deob- 
struent. Various local applications to the limb afford the patient 
comfort, if they do not more ; but some of them, in certain stages, 
are productive of decided good. A bran poultice, applied so as to 
cover the whole limb, acts, in some instances, very soothingly, and, 
what is nearly as good, is warm, dry bran, in a flannel bag, large 
enough to completely envelop the extremity. Cotton batting, in 
sheets large enough to cover the whole of the limb, is used by some 
practitioners. This last may be covered again with oil-silk, so as 
to keep the part dry and of equable temperature. Dry flannel, 



552 PHLEGMASIA ALBA DOLENS, OR CRURAL PHLEBITIS. 

in sheets, wrapped several times around the limb, or in the form of 
a roller, commencing at the toes and extending to the upper part 
of the thigh, will occasionally afford a grateful support. Flaxseed- 
meal poultices, corn-meal mush poultices, camomile flowers in bags, 
wet in some instances and in others dry, hops in the same way, 
&c, are all applicable and often beneficial. The above array of 
local applications will enable the practitioner to select suitable 
ones for his patient, and it will generally be found that some of 
them will agree well in some cases and afford no relief in others ; 
and again, some of them will be praised by the patient in the early 
part of the same case, and replaced by others before the end of 
the treatment. The same may be said of the different kind of 
liniments, oils, and ointments, so frequently resorted to. Soap 
liniment, camphorated oil, oil and laudanum, chloroform and lin- 
seed oil in equal quantities, tincture of aconite, camphor ointment, 
mercurial ointment, ointment with opium, belladonda, hyoscyamus, 
and other anodynes, may all be employed for the purpose of sooth- 
ing and quieting the pain in the limb. After the acute symptoms 
have subsided, and the stiffness of the leg remains, combined or 
not with soreness and pain, the character of the treatment must be 
changed. The tonics and iodine alteratives may be given inter- 
nally. Iron, tinct. cinchona, and, in fact, any of the bitter tinc- 
tures, would be very applicable to support the strength of the 
patient. Travelling to the seaside, a residence at some of the 
popular watering-places, or other equally complete change in the 
residence and circumstances of the patient, may be made to con- 
tribute very materially to the general health of the patient, and 
hence promote the absorption of the deposit in the limb. Much 
good may be done by local means to aid in restoring the usefulness 
of the member. If there are enlarged and varicose veins, the 
silk stocking, or the flannel roller, applied as far as the knee, will 
be of great service. The appliances have a good effect upon the 
deposit, and assist in reducing the size of the leg, and making it 
more supple and active, and also frictions, dry or with liniment, 
with a flesh-brush, coarse flannel, or linen towel, repeated as often 
as can be borne without causing much soreness. Great patience 
will be necessary to derive the full effect of any of these remedial 
means. After the tenderness and pain are all gone, electricity 
may be tried to promote absorption. A matter of the utmost im- 



TREATMENT. 553 

portance is exercise. In the beginning of the disease, of course, 
perfect quiet is indispensable to the subsidence of the inflamma- 
tion in the veins. But after the pain and soreness are so com- 
pletely gone from the limb that it gives no direct pain to step with 
it, we should urge the patient to a moderate degree of exercise. 
Exercise, to a moderate degree, on foot, will promote the general 
health, and most powerfully aid other means in rendering the mus- 
cles useful. After the phlebitis has entirely disappeared, there is 
no reason for complete rest of the limb, and I think absorption 
will be very greatly promoted by the use of the muscles. 

The treatment of phlegmasia dolens, occurring under other cir- 
cumstances, although to some extent modified by the locality of 
the affection and the circumstances surrounding it, in the main will 
be the same as in the puerperal state. 



CHAPTER XXXII. 

PUERPERAL FEVER. 

In order to have an intelligent idea of puerperal fever, we must 
remember that the term has been applied by different authors and 
practitioners to almost every form of fever and inflammation inci- 
dent to the puerperal condition ; and that while the patient may 
be attacked with a great variety of diseases soon after delivery, 
not necessarily in any way connected with the state of the system 
at that time, such diseases are almost invariably, if not always, 
modified to a greater or less extent by it. The confused use of 
this term has misled the inexperienced, and been the cause of 
grave error in teaching on the part of the older members of the 
profession. It is plain to the intelligent reader, therefore, that 
we ought entirely to discard the term puerperal fever, or use it 
only in a generic sense ; and in this last case, affix to it a specific 
term, to define the meaning in particular instances. My own pref- 
erence would be in favor of dropping it, believing that the most 
common forms, if not nearly all of them, are inflammation, and its 
consequences, of particular viscera, or collection of viscera. I 
desire to be understood, therefore, as using this term in a general 
sense ; and I will try to so define the subjects treated of under it, 
as not to be misapprehended. I think I can express my own 
views better by describing toxaemia as it occurs in the puerperal 
state, sporadically ; metritis, as we observe it sporadically ; and 
metro-peritonitis, in sporadic and epidemic forms ; and I think 
almost every practitioner of experience has observed and recog- 
nized these different forms of puerperal diseases. 

It will be seen by this statement of the arrangement, forced 
upon me by my own observation and reading, that I consider the 
diseases mentioned above identical, essentially, in this and all 
other conditions of the system, but very greatly modified by the 
puerperal state in some instances, and in others, the superadded 
condition of epidemic influence. 



PUERPERAL FEVER. 555 

In justification of the prominence I give to the difference be- 
tween the sporadic and epidemic conditions of puerperal fevers 
and inflammations, I would appeal to medical men of extensive 
observation, as well as my own convictions and observations. 
What a difference in the mortality of accidental cases of inflamma- 
tion of the uterus, and such as occur during the prevalence of a 
devastating epidemic ! All must have observed it. In the one 
class of cases recovery is almost universal, while death is the rule 
in the others ; the intensit} 7 and grade of action being pretty uni- 
form and moderate in the sporadic or accidental variety, while in 
the epidemic form they are overwhelmingly destructive, and all 
this, too, in spite of the most judicious management in both in- 
stances. These differences, no doubt, depend on the impression 
produced upon the general system prior to the actual attack of 
disease, and for which I know no better expression than "epi- 
demic influence." I think no better opportunities are offered than 
occasionally fall under the observation of rural practitioners, where 
there are no hospitals to serve as points of origin, the population 
sparsely situated, and imperfect ventilation impossible on account 
of the open and exposed character of their buildings. 

A severe, fatal, and almost universal epidemic of puerperal me- 
tro-peritonitis, prevailed under my observation in the woods, 
amongst inhabitants of almost strictly primitive habits. The pa- 
tients were attended at their own homes by midwives and phy- 
sicians, both having patients with the disease. In that neighbor- 
hood, the majority of families invaded were from one to three miles 
separated from their neighbors, living in houses without glazing, 
or other hindrance to a perfect ventilation. Under these cir- 
cumstances, death occurred in some instances in less than forty- 
eight hours from the attack, and at least sixty per cent, of the 
patients died. 

Those who have seen epidemics prevail in frontier rural dis- 
tricts, cannot resist the idea of an all-pervading influence affect- 
ing the whole community, — predisposing to diseases that are de- 
termined in their nature by circumstances attaching to the indi- 
vidual patient, the prevalence of which cannot be accounted for 
from the narrowed opportunities of contagion or infection alone, 
but which may, nevertheless, be rendered more unerring in their 
onslaught by these two additional, efficient, and co-operating causes. 



556 PUERPERAL FEVER. 

This all-pervading, incomprehensible, subtle, and deadly influence, 
is what I mean by " epidemic influence." ' It is manifest in numer- 
ous attacks, in limited districts, of a peculiar incurable form of 
pneumonia, decimating neighborhoods in sparsely settled countries 
noted for their general salubrity ; or, under similar circumstances, 
erysipelas becomes malignant and deadly in its nature. 

The observation of intelligent practitioners as to the incursion 
of destructive epidemics in the healthy districts of the compara- 
tively wild regions of the northwestern portion of this continent, 
where marsh miasm cannot, by any possibility, be dragged into 
the account, may yet exercise a wholesome check upon the vaga- 
ries of hospital attendants. We have the same forms, the same 
grades, the same deadly epidemics, in the woods and prairies of 
Indiana and Illinois, that are described by the Parisian and Lon- 
don practitioners, or any of the other Eastern writers, as hospital 
in their origin and propagation. 

I desire to make a record of this fact, because the circumstances 
that will admit of a repetition of the observations are rapidly 
giving place to an entirely different state of things, particularly 
with reference to the houses, habits, and diet of the people. These 
remarks are based upon observations extending back for thirty 
years, to the days of poverty in this country, when the mode of 
living more nearly approached the natural than they do now. A 
number of different kinds of epidemics have prevailed under my 
observation in that time, and among them, one of puerperal me- 
tro-peritonitis, which was well described by Gordon, Hay, Lee, 
Armstrong, Gooch, Velpeau, Baudelocque, and others. This epi- 
demic of puerperal fever occurred in the years 1838, '39, and '10, 
in a neighborhood noted for its good health. I may mention in 
passing, that this epidemic was most successfully treated accord- 
ing to the instructions given by Gordon and Hay. 

So far as I am able to form a judgment with reference to that 
epidemic, and others I have since encountered, there were no ob- 
vious causes for the spread of the disease at that time; no apparent 
causes that were not present in as full perfection when the epi- 
demic did not prevail as when it did. We are hence compelled to 
fall back upon some general explanatory term that may account 
for the effect which alone we perceive. Epidemic influence not 



PUERPERAL TOXEMIA. 557 

only causes a difference in frequency of attacks of disease, but it 
impresses on it a modification or peculiarity in each instance. 

Toxcemic puerperal fever is often attended with phlebitic in- 
flammation, but not always. As a sporadic affection, it is gener- 
ally mild, recovery being the rule; and when epidemic, is probably 
the least dangerous of any other variety of acute inflammation 
or fever in the puerperal state. In some epidemics it is mild, in 
others exceedingly fatal. This is, doubtless, the form of puerperal 
fever described by Dr. Butler as prevailing in Derbyshire, in 1765 
to 1775, and alluded to by Dr. Gooch, and which was cured by a 
gentle cathartic of rhubarb and cordial, administered every day 
until the stools became natural. 

The attack takes place from four to ten days after labor, and in 
rare cases later. It is generally ushered in by a chill of greater 
or less intensity, sometimes amounting to severe rigors, but gene- 
rally confined to a sense of chilliness. The chilly feeling recurs 
frequently throughout the fever, and sometimes with so much regu- 
larity as to induce the suspicion of periodicity; at others quite ir- 
regularly, but once or oftener in twenty-four hours. The skin is 
more than naturally warm, and for a good part of the time bathed 
in perspiration; sometimes the perspiration is very copious, and 
occurs at night, or whenever the patient falls into sleep. The 
tongue, at first, is nearly coated with light white fur, but is other- 
wise healthy ; it afterwards becomes dry and red, and coated w T ith 
a dark layer, or is clean, red, chapped, and dry. There is gene- 
rally thirst in the beginning, which may continue, but more fre- 
quently subsides, and leaves the patient in a few days. The ap- 
petite is usually poor, if not entirely absent. The pulse ordinarily 
is rapid, ranging from one hundred and twenty to two hundred in 
the minute, but soft and compressible, each stroke sometimes giv- 
ing the sensation of a thrill, instead of the solid shock of sthenia. 
In the milder forms it seldom goes above one hundred and thirty, 
and is more frequently above one hundred and twenty in the 
minute. The nervous system is almost always, comparatively, se- 
riously affected; the patient is wakeful, apprehensive, and despond- 
ent. When sleep does come, it is generally disturbed and dreamy, 
and the patient often wakes unrefreshed, and believing that she 
has not slept, bhe often talks and starts in her sleep, the tendons 
twitch, and she becomes decidedly delirious, but when aroused she 



558 PUERPERAL TOXEMIA. 

is conscious, answers questions, and talks intelligently. In other 
instances not so common, she is stupid, and sleeps a great deal, 
mutters and moans, and works the muscles of the face with grimaces. 
The stomach is not generally affected much; there is not often 
nausea or vomiting, or other disagreeable symptoms connected 
with it, but the bowels are generally very much deranged. Diar- 
rhoea is one of the very common symptoms. The stools are thin, 
dark-colored, and fetid. The diarrhoea is not generally, but some- 
times, a very early symptom, coming on after other symptoms of 
the fever have been in existence for some time ; at others, it begins 
first. The abdomen is generally somewhat, though not excessively, 
distended with gas; the tympany is hardly perceptible in many 
other instances. In severe and fatal cases, toward the last, the 
intestines become considerably distended. There is not ordinarily 
much pain; sometimes there is severe pain attending the begin- 
ning or progress of these cases, and generally, there is but slight 
sense of soreness over the uterine region and ilia. The pain is 
sometimes situated in other than the abdominal region, as the 
shoulders, arms, head, and elsewhere, and seem- to be neuralgic 
in character. The lochia and milk continue to flow usually for 
several days, but the secretion of milk diminishes at first, and 
progressively becomes less until it entirely ceases ; the lochia how- 
ever, is not often much affected in quantity, but in quality is fetid 
and very offensive, at once suggesting the idea of putrefaction. It 
is also so acrid, sometimes, as to excoriate the parts over which it 
flows. 

During the progress of this fever, even when comparatively mild, 
there often supervenes intense inflammation in some organ distant 
from the pelvis. One of the lungs, for instance, becomes the seat 
of general inflammation, and the advance is oftentimes so rapid 
that it is completely engorged in twenty-four hours. No air pene- 
trates further than the large bronchi ; vesicular sounds of all sorts 
give place to bronchial respirations and bronchophony. Some- 
times in four or five days these phenomena pass completely off and 
the same process is set up in the opposite side, or some other part 
of the system suffers from a similar sudden invasion of inflamma- 
tion. But not unfrequently the pneumonia passes into the stage 
of real hepatization, and the organ if not permanently spoiled is 
a long time in recovering from the consequence of this severe 



DIAGNOSIS, COMPLICATIONS, PROGNOSIS, AND CAUSE. 559 

attack. All the large joints, the knee, shoulder, and elbow, and 
some of the smaller, are liable to these sudden and severe attacks 
of inflammation. It may likewise in them prove to be evanescent, 
or permanent and destructive. Even the muscular system, such 
as those of the thigh, leg, arm, back, and chest, are also compli- 
cated. Large bags of pus may thus be formed. I have a case in 
my care now where the left thigh has just been relieved by incision 
of a large collection of pus. 

The duration of this toxemic form of puerperal fever is often 
protracted, continuing for many days, and even weeks. Three, 
six, or even ten weeks, may elapse before it subsides entirely, and 
the declination is so slow, as to be hardly perceptible from one day 
to another. Sometimes its progress is extremely and disastrously 
rapid, overwhelming the powers of life in a few hours. 

Diagnosis. — The diagnosis is not difficult, I think. The diar- 
rhoea, want of pain, and tenderness of the abdomen, copious per- 
spiration, &c, mark the difference between it and the inflammation 
proper. 

Complications. — We sometimes meet with cases in which, with 
these symptoms, there is unmistakable evidence of inflammation 
of the uterus, as evidenced by pain and tenderness over the uterus, 
an enlargement of that organ, suppression of the lochia, &c. And 
sometimes we also have signs of peritoneal inflammation, which I 
shall describe when I come to speak of it. 

Prognosis. — This will depend almost wholly on the general epi- 
demic constitution. There can be but little doubt that it occa- 
sionally, though rarely, appears in a very fatal form epidemically ; 
but usually, the epidemics of this kind of puerperal disease are 
mild, and in the large majority of instances they terminate favora- 
bly, and require very little treatment. As I have seen it sporadi- 
cally^ it scarcely ever proves fatal. When it does terminate unfa- 
vorably, it does so generally by exhaustion, as the effect of its long- 
duration and profuse cutaneous and intestinal discharges. 

Cause. — From the offensive character of the lochial discharge I 
have been inclined to believe that it almost invariably arises from 
absorption of the products of decomposition. Indeed, I think I 
have seen some instances traceable to retention of pieces of pla- 
centa or membranes until decomposition takes place. From in- 
efficient uterine contractions, accumulations of blood in the uterus 



560 PUERPERAL TOXEMIA. 

may result, and remain until they become putrid, and thus furnish 
the material for absorption and poison. So far as my observation 
is sufficient upon which to base an opinion, I would say that this 
is the manner of organization in sporadic cases. Where it prevails 
as an epidemic, there is doubtless a general predisposing cause 
operating upon the whole community, rendering the exciting cause 
I have mentioned efficient and operative when applied in a slight 
degree. 

Nature and Morbid Anatomy. — As I have before intimated, I 
think this form of puerperal disease is a true toxaemia or septicae- 
mia. We know so little about acute diseases of the blood that I 
have not sufficient data upon which to base a theory of this affec- 
tion that will admit of minute application. Whether in the blood 
is set up a series of changes that result in an alteration of its com- 
position to such a degree as to induce these morbid phenomena, or 
whether the functions are disturbed thus gravely by the circula- 
tion of the small amount of poison admitted in this fluid in its 
original state, or while undergoing further chemical changes, are 
questions we may fairly conclude as unanswerable in the present 
state of science. I am inclined to believe the latter to be true in 
a general way. But, in cases of overwhelming epidemics, may we 
not suppose very plausibly that the predisposition consists in such 
a state of the circulating fluid as will permit of a rapid decompo- 
sition in it, or septicaemia? However this may be, the main differ- 
ence between the mild sporadic form and the rapidly fatal epidemic 
variety would seem to be the preservation of the integrity of the 
composition of the blood in the one, and the sudden reduction of 
it to a state but little better than putrilage in the other. 

Recorded facts attest very positively that instances of this form 
of fever are not unfrequently observed which run a very rapid 
fatal course, and yet present no traces of disease in the solid 
organs after death. More frequently, however, the fatal cases are 
attended with post-mortem evidences of metritis, phlebitis, perito- 
nitis, or all these combined. Hence we cannot regard this fever 
as possessed of a morbid anatomy in the proper sense of the term. 
The inflammations of the pelvic and abdominal viscera I regard as 
complications, instead of essential portions of a whole. I cannot 
refrain from remarking in this connection that, in my opinion, the 
combination of this toxaemia with the dangerous inflammations of 



TREATMENT. 561 

the uterus and peritoneum, has formed the true nature of some of 
the most appallingly fatal epidemics on record, and that it is for 
the want of the philosophic contemplation of this mixed or com- 
plicated variety that has given origin to so much acrimonious and, 
in many instances, unprofitable debates as to the nature of puer- 
peral fever. Of course, toxemia is always attended with an as- 
thenic grade of febrile reaction, and the more decided this item in 
any given case, complicated or simple, the more rapid the declen- 
sion of the powers of life. Inflammations, attended with an in- 
tense toxaemia, are, as a consequence, influenced by it, and must 
fall under the general head of asthenia. I do not wish to antici- 
pate what I shall have to say of this complication under the head 
of puerperal peritonitis, and will only add that, unattended by 
toxaemia, the inflammations of the puerperal state are not essen- 
tially different from the same disease occurring in the same organs 
at other times. 

Treatment. — From what I have said as to the nature of this form 
of fever, the student will very properly infer that the treatment is 
alterative and supporting. We should endeavor to stop the pro- 
cess of poisoning, and support the system until the fever has spent 
its force. The probability is that the first item may be furthered 
by remedies that enter the blood, and there influence the elimina- 
tion, neutralization, or destruction of the poison in that fluid. The 
first thing, however, that presents itself for correction is the state 
of the contents of the genital canal. The uterus and vagina should 
be kept clean as possible, and no substances allowed to remain 
long enough in them to undergo decomposition. To this end, 
copious vaginal injections are indispensable. It will be well to 
make these injections of some soapsuds. The patient may be 
placed on a bed-pan, and half a gallon of suds, made of fine toilet 
soap, passed through the vagina by means of one of those perpetual 
syringes. This may be done every eight or twelve hours, as the 
foulness of the discharges may require. A teaspoonful of carbo- 
nate of soda to a quart of water is highly detergent, and may be 
advantageously used. We are also to attend to the contents of the 
uterus, not by injecting water in its cavity, but the organ should 
be examined with the finger, so as to be sure that the mouth is not 
occluded with a clot of blood or membrane. The finger may very 
properly be introduced into the mouth of the uterus to encourage 

36 



562 PUERPERAL TOXEMIA. 

the discharge of imprisoned fluids. Whether in certain instances 
it might not be advisable to throw water into the cavity of the 
uterus, my observation does not enable me to determine. The 
organ may be pressed and agitated somewhat to aid in voiding its 
contents. This is for the purpose of preventing further ingress of 
poison into the blood. We may aid nature somewhat in the excre- 
tion of it. To assist in its elimination we may encourage a soluble 
condition, when necessary, of the bowels, as being favorable to the 
early resolution of the case ; and we should not interfere to re- 
strain the diarrhoea, unless it is clearly exhausting the powers of 
the patient. It will not be inappropriate, when the evacuations 
from the bowels are not' very copious but very offensive, to admin- 
ister from four to ten grains of rhubarb and the same quantity of 
carbonate of soda, to promote the excretion and neutralization of 
the offensive substances in the stomach and bowels. Hyd. cum- 
creta, in from three to five-grain doses once a day, will have a like 
effect. The skin should be thoroughly cleansed with tepid soap 
and water twice a day, and then sponged afterwards with a weak 
solution of hydrochloric acid each time. The sulphites of lime 
and soda are now administered to arrest septicaemia, or neutralize 
the poison circulating in the blood ; and although my experience 
in their use in this form is limited, I am disposed to favor their 
use as probably promotive of that end. We may give the sul- 
phite of lime in doses of 5j, mixed with water, three or four times 
in twenty-four hours. It is, I think, the pleasanter of the two, 
and perhaps as beneficial. I have been very much in the habit of 
giving the chlorinated tincture of iron — ten drops every two or 
four hours in plenty of water — for the double purpose of exerting 
a tonic and antiseptic influence. When there is great depression, 
we should endeavor to derive all the benefit possible from tonics. 
Sul. quinia is an excellent tonic in such cases, and may be given 
with the tincture of iron. Two grains every two or four hours is 
a suitable quantity as a general thing. The iron and quinia may 
and ought to be persevered in when there is much prostration. If 
there is very great prostration, to these may be added alcoholic 
stimulants, of strength and in quantities indicated by the grade 
and intensity of the symptoms. Wine will do in the milder forms, 
while brandy, variously mixed with milk, water, broths, &c, will 
be necessary in great copiousness in the very severe forms. Of 



TREATMENT. 563 

course, these medicinal tonics and stimulants are but temporary in 
their effects, and it will be necessary to give nourishment to pro- 
duce permanent results. Probably the tonics do good by promot- 
ing the digestion and sanguification of the nourishment taken ; for 
this toxaemia is the very state of the system in which the patient 
may eat and digest but not be nourished. The great function of 
sanguification being in abeyance, brandy and milk may be mixed 
as stimulant and nourishment. Beef essence, beef tea, mutton 
soup, chicken tea or soup, and, in fact, any of the animal broths, 
may be given in such quantities as the patient can take, are always 
in place, and should all be mixed with stimulants, to promote the 
changes necessary for nutrition. 

In addition to this treatment, we may often do much to prevent 
exhaustion and ameliorate the sufferings of our patient, by the use 
of astringents and anodynes. When the bowels are moved exces- 
sively, opium and tannin combined will be very efficient in restrain- 
ing them, and thus closing the exhausting outlets. A mixture I 
have used with much advantage in correcting the character of the 
intestinal secretions, allaying the irritation of the alimentary canal, 
and soothing the nervous system, is made as follows, viz. : 

R- Tinct. opii deod., 
Magnesia sul., 
Acid sul. arom., aa . . . . . . gij. 

Mua, iij. 

Mix and dissolve. 

A teaspoonful every four hours or often as necessary to answer 
these purposes. The opium may be increased in the mixture to 
meet the indications in different cases. Sometimes, when there is 
no substance to the stools, 5ss. tinct. opii deod., and 5jss. tinct. 
rhei, mixed, and given in 5j doses, produce very favorable effects. 

The indications for astringents ought to be plain before they 
should be energetically used. We ought merely to moderate the 
diarrhoea when there is reason for interfering, desiring by such 
interference, to prevent exhaustion. Opium given alone, or com- 
bined with stimulants, is necessary and useful in most cases. The 
patient very often passes sleepless nights from nervous watchful- 
ness, and if there is no idiosyncratic objections to opium, may 
generally be quieted into grateful slumber by it. When opium 
cannot be borne, grs. v of ext. hyoscyamus may be occasionally 



564 PUERPERAL METRITIS. 

substituted. I have recently, in some cases, found much good to 
result from the administration of bromide of potassium in scruple 
doses at bedtime, and repeated in four or six hours ; or bromide 
of ammonia in two-grain doses every four or six hours. This last 
may be given in some kind of syrup. The valerianate of ammonia 
in syrup, given in six or eight-grain doses every four or six hours, 
is an admirable anodyne stimulant when the patient is very nervous 
and wakeful. This treatment is, of course, adapted to compara- 
tively mild cases of toxsemic puerperal fever, and would not be 
sufficiently energetic for those cases of overwhelming severity at- 
tended with extensive inflammation, and I must refer the reader 
to puerperal metro-peritonitis for treatment in such instances. 

Puerperal Inflammation of the Uterus — Puerperal Metritis. — 
Inflammation of the substance of the uterus is probably of all 
puerperal affections the most frequent. It commences generally 
with a chill of greater or less intensity, usually not very severe, 
which is succeeded by febrile excitement. When reaction is estab- 
lished, the bones and head ache, the surface is hot and generally 
dry, the pulse accelerated and somewhat firm. The pulse is not 
often very rapid, seldom exceeding 110 or 120 in the minute. The 
patient complains of pain, pretty severe, and sometimes excruciat- 
ing, in the hypogastrium, or one of the iliac regions ; and, upon 
examination of the lower part of the abdomen, a well-defined 
tumor is perceived, formed of the uterus, which is exceedingly 
tender to the touch. The tongue is white and moist ; sometimes, 
though not always, there is nausea, and the bowels are generally 
constipated. When the patient has a stool, it often gives her con- 
siderable pain. There is also, frequently, an urgent desire to uri- 
nate, which is sometimes attended with pain. The pain in the 
region of the uterus is generally dull and aching in its character, 
but sometimes there are exacerbations of greater severity. The 
lochia, in this form of metritis, is always scanty, if not entirely 
suppressed. I think it is almost always entirely suppressed. The 
secretion of milk is not generally much affected at first, but if the 
disease continues for a number of days it. generally becomes very 
scanty, and finally fails. The time of the attack varies from the 
third or fourth day to the fourteenth. It sometimes seems to re- 
sult from the first efforts to sit up, or resume ordinary avocations 
or habits, continues with some intensity for from one to three 



TREATMENT. 565 

weeks, and terminates in resolution or chronic metritis, which runs 
on indefinitely. I have never observed a fatal case of this kind 
of uncomplicated sporadic uterine inflammation. 

Diagnosis. — This is not diflicut, and will, for the most part, be 
sufficiently clear from the ordinary history and symptoms of the 
case; but, if doubt exists, it may be removed by physical exami- 
nation. By introducing two fingers in the vagina, and tenderly 
surveying the pelvis, pressing upon the sides of the pelvis high up 
towards the ovaria, upon either side, the bladder, rectum, and 
uterus, we will find the inflamed organ. It will be still more plain 
if, with the other hand, we press upon the uterus above the pubis, 
and thus include it between the two hands. If the uterus is the 
organ inflamed, there will be pain when we exert pressure with 
either hand in this position. 

Causes. — The cause is generally traceable to an unusually diffi- 
cult labor, in which the uterus has been extraordinarily excited 
for a long time, torn, bruised, or otherwise damaged, — the appli- 
cation of cold, improper or too early exertion, stimulating drinks, 
excessive passion, &c. In this sporadic form of acute inflamma- 
tion of the uterus after delivery, none of the effects of contagion, 
epidemic influence, want of ventilation, or other deleterious influ- 
ence acting upon the blood, operate as a cause ; on the contrary, 
the causes all seem to directly influence the uterus itself. 

The prognosis is favorable ; the disease, as I have before re- 
marked, generally and even spontaneously terminating in resolu- 
tion. It may be protracted for a considerable time by inefficient 
treatment or imprudent conduct, and run into the chronic form, 
but probably never directly proving fatal. 

Treatment. — The treatment of ordinary sporadic metritis is 
simple and generally successful. It is, in the main, antiphlogistic 
and alterative. Most practitioners, I think, following the teach- 
ings of the present times, fall short of efficient energy when they 
act in the right direction. I am free to say that I have more fre- 
quently erred in the omission of the use of antiphlogistic remedies 
than any other way, and that I have been more gratified with the 
effect of them than any other measures in these cases. If the 
patient is robust, we omit one of the most useful means of cure if 
we do not bleed enough to produce a decided impression early in 
the course of the case. And my experience is decidedly in favor 



566 PUERPERAL METRITIS. 

of venesection to a degree closely approaching syncope. It almost 
invariably breaks the force of the disease if done within twenty- 
four hours after the attack, and paves the way for complete suc- 
cess in the use of other less energetic measures. If the patient is 
not sufficiently robust to bear such a decided bleeding, we may 
cup over the sacrum, so as to draw ten or fifteen ounces of blood, 
or place over the hypogastrium twenty leeches, and allow the bites 
to bleed as long as they will afterward. Decided sanguineous de- 
pletion is the most important remedy in the beginning of the dis- 
ease, and it should be measured by its effects upon the patient at 
the time it is used. After the first forty-eight hours, the benefi- 
cial effect of bleeding will be less marked, but still local depletion, 
with cups or leeches, will be useful, and ought not to be omitted. 
A good active cathartic should follow the bloodletting almost im- 
mediately. Hyd. mit. chl., grs. iv, to be followed up by the citrate 
of magnesia, sul. magnesia, or other agreeable and active saline 
cathartics, in sufficient quantity to act briskly, may be used to 
great advantage. If the pulse should be quick and frequent after 
these means, we may very properly administer of tinct. verat. 
virid., gtt. iv, every three or four hours, until its sedative effects 
are positive. At night, and even at other times, it will be very 
proper to quiet the nerves of the patient and relieve the pain with 
a good, liberal dose of opium. If the case should last without 
very decided relief four or six days, our treatment should -be 
shaped so as to induce a scarcely perceptible mercurial influence 
upon the system. One grain of submur. hyd., twice a day, will 
usually do this in a very short time and gentle manner. During 
the treatment, the bowels ought to be kept in a soluble condition 
by saline cathartics. After the specific sedative effects of the 
verat. virid. are produced, we ought to keep it up by giving half 
as much as at first. We will be able to derive much good from 
emollient applications in the early part of the disease. Among 
these, the best of them, I think, are corn or Indian-meal mush 
poultices, the water compress, — made of several folds of napkin or 
towel wet in tepid water, and covered with a dry bandage, — fomen- 
tations of hot vinegar and water, &c. In the advanced states, 
counter-irritation over the hypogastrium is very serviceable, pro- 
vided the patient is not too sensitive to such measures. When the 
mercurial alterative is not deemed applicable, the iodide of potas- 



CAUSES AND NATURE. 567 

sium, in eight or ten grains, three times a day, may be sometimes 
profitably substituted. It will hardly be necessary to remind the 
student that the more perfectly quiet the patient can be kept 
during the treatment, the more complete and speedy the cure. 
It may not be amiss, also, to say, in this connection, that an in- 
flammation in the acute form is more easily cured than after it has 
become chronic, and that our efforts should be continued until it 
is completely removed — not merely mitigated. 

It would not be inappropriate in this place to describe puerperal 
perimetritis, but instead of doing so, I will merely refer the reader 
to the description of this affection in another part of this book, 
under the general title of Perimetritis. 

Puerperal Metro- peritonitis — Causes and Nature. — Puerperal 
metro-peritonitis consists in extensive and generally overwhelming 
inflammation of the uterus, peritoneum, and other pelvic and ab- 
dominal viscera, and occurs sporadically and epidemically. We 
are to regard a case as sporadic, when it is the only one in a hos- 
pital, or given district, — an isolated case. The epidemic variety 
is represented by a number of cases in a hospital or neighborhood 
taking place together, or at short intervals from each other. There 
are differences between cases occurring sporadically and epidemi- 
cally, so marked, that a casual observer will easily distinguish 
them. It is important that the distinction be made, for various 
reasons, which will appear as I advance in the consideration of the 
subject ; and I beg the reader to bear in mind the difference be- 
tween sporadic and epidemic forms of metro-peritonitis, as essential 
to an intelligent treatment of any given case. 

The causes of sporadic cases are generally obvious and acciden- 
tal. Damage done in producing miscarriages, the effects of drastic 
or perturbating medicines used for the same purpose, excitement 
from strong passions, as anger, hatred, or the effects of depression, 
of melancholy, mental anxiety, and alcoholic stimulants, occasion- 
ally act as causes of puerperal metro-peritonitis. Incautious expos- 
ure to cold during or immediately after labor, severe labor, pro- 
tracted too long, also, may be considered as causes of the sporadic 
form. Generally, the disease may be traced to some of these ob- 
vious accidental circumstances. It is almost, if not always, sthenic 
in character or grade of vital action. The only exception to this 
is when the system of the patient has been predisposed by clebili- 



568 PUERPERAL METRO-PERITONITIS. 

tating influences to an asthenic condition. There is nothing in its 
etiology to give it an asthenic phase. 

As an epidemic, the above causes seem to have almost no influ- 
ence in propagating it, and no precaution in the circumstances of 
the patient or labor will insure immunity from an attack. The 
disease is caused, continued, and impressed with its peculiarities, 
by an epidemic influence pervading whole communities, preparing 
the system of its victims during pregnancy for the disastrous at- 
tack that follows delivery. According to the preparatory effects 
of the epidemic influence, will be the grade of vital action. In 
some epidemics it will doubtless be sthenic, and the disease of a 
tonic character, requiring for its cure antiphlogistic treatment; in 
others, it will be asthenic in a high degree, and the vitality is al- 
most annihilated by the predisposition and force of the attack, at 
once prostrating the patient beyond all hope. 

Epidemic influence, in this view, is not only the predisposing, 
but the qualifying cause ; and it will be seen further that the quali- 
fying impression may be very different in different epidemics. 
Each epidemic must be, therefore, studied separately and compar- 
atively, in order to understand and treat it intelligently. It is 
only where this strong predisposition exists, that contagion can be 
reckoned as a cause, if at all, of puerperal peritonitis. The same 
may be said of the etiological effects of unclean hands. When 
there is no epidemic influence, the disease will not be carried from 
one patient to another, by practitioners, as it occasionally appears 
to be done. 

I do not argue against contagion as an occasional cause, but I 
very much doubt whether it is ever more than co-operative in its 
effects. 

It would seem that other forms of disease often prevail in these 
epidemics contemporaneously with puerperal metro-peritonitis. 
Drs. Gordon, Armstrong, Hay, Lee, and others, observed in sea- 
sons of epidemics of puerperal fever, the prevalence of erysipelas, 
putrid angina, scarlatina, and typhus, with an unusual tendency 
to hospital gangrene and erysipelas. This will strengthen the idea 
of a general epidemic proclivity to a certain character of disease. 
The causative effects of epidemic influence are greater sometimes 
than others. We sometimes meet with epidemics in which not 
more than five per cent, of parturient patients are affected by it, 



CAUSES AND NATURE. 569 

and, perhaps, even a less proportion than this ; while again fifty, 
seventy-five, and even a larger ratio, are unfortunate. I think 
the virulence of attack corresponds to some extent with the fre- 
quency of occurrence. Where the cases are few the intensity is 
less than when there is an almost universal predisposition. 

The beginning of an epidemic is often marked by the exceeding 
violence of the cases observed; while at the decline, cases are very 
much milder and less fatal. 

Bearing in mind the difference in the intensity and nature of the 
epidemic impressions produced by each season, set of surroundings 
and localities, we will be prepared to understand and estimate the 
numerous and contradictory statements of experiences and opinions 
of the many able observers and writers on this perplexing sub- 
ject. The modifying influence of this great predisposing cause is 
apparent in the dissection of persons dead of the disease. In spo- 
radic cases, the inflammatory effusions are plastic, and resemble 
in appearance those of peritoneal inflammation occurring at other 
times and under different circumstances; in some epidemics, such 
is likewise the case, but in others, the exosmotic products are 
aplastic, or exhibiting strong chemical qualities, and are grumous, 
offensive, and sometimes almost putrilaginous. 

The appearance of the products of inflammation has led to acri- 
monious disputes as to the nature of the disease, one party con- 
tending that it is a peculiar fever, while the other could see nothing 
in it but inflammation; the first considering the pelvic and ab- 
dominal appearances one of the conditions of the fever, secondary 
in importance, in fact, of no importance at all, and not always 
present; while the second believe the inflammation, the disease, 
and the phenomena of the fever, of no farther importance than 
is usually attached to symptoms. It is probably impossible to 
decide which of these is right, or whether they are not both wrong 
for taking extreme positions. It will be inferred from what I have 
stated that I consider it a true inflammation, but that the inflam- 
mation partakes of a sthenic or asthenic form, according to the 
effects of the epidemic influence at different times exerted. 

While upon the subject of difference of opinions as to the na- 
ture of epidemic metro-peritonitis, it may not be inappropriate to 
state that the success or failure of a particular sort of treatment 
is supposed to decide the question as to whether the appearances 



570 PUERPERAL METRO-PERITONITIS. 

are the result of inflammation or fever. Some argue, and the 
argument is generally accepted by the other party, that if it is 
inflammation, depletion and the energetic pursuance of the anti- 
phlogistic treatment will cure it; and as this is not always the 
case, it must be a peculiar fever. Just as though the old notions 
of an invariable methodical array of remedies were always ap- 
plicable and beneficial in all inflammations, when the truth is, we 
have all learned that the evacuant mode of treating it is not al- 
ways or even generally the best. The pneumonia, for which we 
were once in the habit of depleting so copiously, is still pneumonia, 
although we have ceased to treat it as formerly. Questions of 
sober seriousness to the practitioner of long experience, who has 
outlived the old regime, is, whether he was right when he let blood 
so copiously twenty-five years ago, or whether there has not been 
a great modification of the human constitution, or of the vital 
grade of the disease, from some peculiar influence. The man of 
wisdom will never dismiss these questions, but continue watchfully 
and carefully to investigate them while his responsibilities last, 
not only with reference to pneumonia, but puerperal fever, and 
every other form of disease, and hold himself as open to con- 
victions in favor of another change of treatment when philosophi- 
cal observation leads the way, as he has shown himself to desert 
his old plan, when proven inapplicable to disease as it now exists. 
The fetters of habit and association bind many a practitioner to 
error at the expense of valuable lives ; and the only way to avoid 
this danger, is to make every important case a test of the truth 
or falsitv of our doctrine, formed from the observation of former 
ones. 

I cannot here avoid the declaration, that there is something in 
the symptoms, anatomy, and treatment, of all the epidemics of 
motro-peritonitis on record, that completely and convincingly 
stamps the disease under consideration as inflammation, in the 
light of a liberal and intelligent understanding of that pathologi- 
cal condition. But I am also ready to admit, in some epidemics, 
and, indeed, urge, the coexisting, all-pervading depravity of the 
fluids (so pertinaciously presented as evidence that the disease is 
a malignant fever, and not an inflammation), and that this state 
of the blood — with corresponding depravity of innervation — is just 
what makes the difference between different epidemics. 



MORBID ANATOMY. 571 

The observer will find the disease sthenic in some epidemics, and 
asthenic in others, but always inflammatory ; and the welfare of 
his patients and his own reputation will depend largely upon an 
accurate determination of all questions in this respect. 

Morbid Anatomy. — Upon opening the abdomen, obvious signs 
of extensive and terrible inflammation present themselves. The 
intestinal canal is generally very greatly distended with gaseous 
accumulation, and the peritoneal cavity contains much serum, 
sometimes colored with blood, sometimes mixed with pus in various 
quantities, with coagula of fibrine, &c. At other times the serum 
is fetid, acrid, greasy, and almost a putrilage. The fluid contents 
of the abdomen, in patients dying of puerperal peritonitis, has the 
reputation of being highly poisonous in its effects upon the dis- 
sector, and instances of death from dissection-wounds in these 
cases are numerous. It is also regarded as imparting to the 
hands an infection that is difficult to get rid of. 

The peritoneum is usually lightly colored upon its visceral layer, 
as well as its extension upon the abdominal walls. But in rare 
cases, where the symptoms, during life, indicated it, the evidences 
of inflammation are said to be entirely wanting, or at most only 
to exist in a very slight degree, a little bloody serum being all that 
is present. 

In addition to the redness and effusion of serum, we mostly find 
also fibrous patches or layers of false membrane covering the peri- 
toneal surfaces. These patches on a red base give the membrane 
a mottled appearance. The fibrinous effusion is occasionally so 
copious and so firm as to agglutinate the intestinal convolutions, 
so as to mass them together in a great lump of inflammation, or it 
glues them to the uterus, bladder, and sides of the abdomen. In 
some cases, the fibrine, is destitute of adhesive qualities, or pos- 
sesses it in a very slight degree, and it may be scraped off the sur- 
face to which it adheres, and is not much more tenacious in con- 
sistence than cheese. When the uterus is cut into, it may be 
found healthy below the peritoneal lining, presenting in every way 
the normal appearance ; but generally there are strong manifesta- 
tions of the effects of inflammation. The fibrous tissue is softened 
sometimes to such a degree that it may be broken down by the 
finger, and it may be infiltrated with pus. Sometimes the pus is 
collected into small abscesses in various parts of it. 



572 PUERPERAL METRO-PERITONITIS. 

The lining membrane, even when the fibrous substance is in- 
flamed, may not show much signs of disease, but generally it is 
vascular and softened, sometimes ulcerated, and in more intense 
forms of the disease it is occasionally gangrenous in patches of 
large size. 

In some cases there are collections of pus in the sides of the 
pelvis around the uterus, and in the ovarian regions, these organs 
not unfrequently being involved, and in some rare cases softened 
or dissolved into pus. Abscesses, or collections of purulent fluid, 
may also form in the omental duplicatures of the peritoneum, or 
even in the mesentery. The veins of the uterus, in this tissue, the 
spermatic, hypogastric, iliac, and even the vena cava, have been 
found in a state of inflammation. The lining membrane of the veins 
is deeply colored, apparently stained with blood, and the cavities 
are filled with fibrinous concretions, so as partially or wholly to 
occlude them, and to obstruct the current of blood. In these con- 
cretions, and about them, pus is more or less copiously formed. 
Dr. R. Lee has met with cases wherein this phlebitic inflammation 
is the main, if not the only, anatomical evidence left by the disease, 
the uterus and the peritoneum being otherwise free from any sign 
of disease. More frequently these were more or less combined, 
the whole of the abdominal and pelvic disease being overwhelmed 
in one grand phlogistic conflagration. 

Besides all this localized inflammation, there are sometimes re- 
moter ones, apparently as destructive to the parts attacked, and 
as certainly fatal in their effects. The lungs are overwhelmed 
with sudden inflammation, rapidly leading to gangrene ; the liver 
suppurates ; large collections of pus take place in the joints, or in 
the muscular interstices, on the back, sides of the chest, in the 
nates or limbs. 

As before hinted, it is sometimes a remarkable fact, that in the 
most rapidly fatal cases, no lesions are left behind to point out the 
seat of overwhelming disease. Life is probably extinguished by 
the powerful and extensive impression of the morbific cause before 
the signs can be fixed upon the viscera by vascular action. 

There are no less marked changes in the fluids than the solids 
of the body. The blood, in some patients, shows signs of inflam- 
mation, as pointed out by the authors of the past half century. 
The coagulum is firm, cupped, contracted, and covered with a 



SYMPTOMS AND MODE OF ATTACK. 573 

thick, strong, buffy, or fibrinous coat, after cooling, and when first 
drawn is florid and bright in color. In other cases, and particu- 
larly in some epidemics, the blood presents a very different sort of 
appearance. When drawn, it is dark-colored, and after cooling, 
there are none of the appearances described ; the clot, if formed, is 
dark-colored, flat, large, and loose in texture, so that it easily 
breaks to pieces. There is no buffy covering to it, and much dark- 
colored blood settles to the bottom of the vessel. In still another 
variety of cases, the blood does not coagulate ; it is in a condition 
termed the dissolved state. The serum and globules do not sepa- 
rate, except slightly, and that by the latter settling down to the 
bottom of the cup. 

These different appearances were formerly, and even now are by 
many members of the profession, regarded as signs of the sthenic 
or asthenic forms of inflammation. If the blood separates readily 
into serum and clot, and the last contracts, and is strongly cupped 
on the top, and is yellow or buff-colored, the indication is to bleed, 
because the inflammation is sthenic, and may be cured by it. But 
if the clot is large, loose, soft, and flat, without the buffy covering; 
and, a fortiori, if the blood does not coagulate at all, the inflam- 
mation is asthenic, and bloodletting contraindicated. These old- 
time notions are too little regarded nowadays, and without suffi- 
cient reason are discarded. 

Symptoms and Mode of Attach. — Although, as in every other 
disease, there is some variety in the mode of attack of metro-peri- 
tonitis, it is generally pretty uniform. Most frequently, without 
any premonition, and with the usual health for the circumstances, 
the patient begins suddenly to experience pain in the hypogastric 
region, attended with tenderness upon pressure or movement of 
the body. Then ensues a sense of chilliness, a mere coldness, or 
amounting to rigors, which are sometimes very severe. The attack 
dates ordinarily within forty-eight hours from the time of delivery, 
but several days may elapse before its occurrence. An attack may 
also occur before confinement. These variations as to time are not 
very frequent compared to the whole number of cases. The mode 
may vary occasionally as well as the time. The fever comes on 
gradually before or soon after delivery, so gradually as not to be 
marked in the beginning by any remarkable symptoms. Instead 
of rigors, we may have nausea and vomiting as the first symptoms 



574 PUERPERAL METRO-PERITONITIS. 

in an attack. We sometimes have premonitory indisposition for 
several days, instead of the sudden unlooked-for attack. After 
an attack has merged into a fully formed case, we have fever, pain, 
tenderness, and enlargement of the abdomen. The tenderness and 
pain, in the earlier part of the attack, are confined to the region 
of the uterus, which feels larger than it ought at that time. The 
pain, tenderness, and enlargement, in a few hours, extend over the 
whole abdomen. The distension in mild cases requires two and 
even four days to become great, but in the severe forms it arrives 
at its maximum in a few hours. When we examine the abdomen 
with reference to the distension, we find it to be tympanitic, caused 
by an accumulation of gas in the intestines. In very rare in- 
stances the pain and, enlargement, one or both, are absent, or so 
slight as to escape observation. The fever has some peculiarities 
that at once attract our attention. It is not generally attended 
with a great amount of heat, but the rapidity of the pulse is re- 
markable. It seldom is less frequent than 120 to the minute, and 
very commonly it is much more frequent, running up to 150, 160, 
and even 200 strokes. This excessive frequency of the pulse is 
the rule in the disease. There is not so much pain in the bones 
or head as there usually is in most cases of excessive arterial re- 
action. The pulse varies very much in other properties besides 
that of frequency. It is sometimes small and weak, — I think it is 
seldom very full, — at others, it is hard and sharp, and possesses a 
peculiar thrill. The peculiarities of the pulse of puerperal peri- 
tonitis are rapidity and smallness; besides these it varies as it 
does in other diseases. 

The tongue is at first coated white, and is moist, but it is apt to 
become dry and red, or brown, and even black. The teeth are 
usually covered with a similar coating, which becomes dark sordes, 
not unlike typhus, in some cases ; in others, there is no remark- 
able change in the appearance of the tongue. The stomach ordi- 
narily sympathizes with the general disorder. There is want of 
appetite almost invariably, often nausea, and sometimes, in fact, 
not unfrequently, vomiting. It is singular, however, that we occa- 
sionally meet with cases where the stomach in every respect re- 
tains its comfortable state, if not its complete functional action. 
In other instances, while there is no nausea, vomiting, or gastric 
discomfort, the organ seems to lose all power to respond to or even 



SYMPTOMS AND MODE OF ATTACK. 575 

recognize the presence of anything taken in it, — medicines of all 
kinds, as well as nourishing ingesta, lying in it inert and useless; 
the vitality, as well as sensibility, being entirely lost. When there 
is vomiting, the change in the character of the ejections mark the 
progress toward an unfavorable issue. The ejections, being at 
first only the ingesta, become acrid, green, mucous, bloody, 
grumous, &c, until the coffee-grounds emesis of other malignant 
forms of disease is imitated. The bowels are often not at all dis- 
turbed, particularly at first. They are generally torpid, but some- 
times there is diarrhoea in the beginning, which remains a more or 
less obstinate and urgent symptom during the whole course of the 
disease. When there is diarrhoea, the discharges are apt to ad- 
vance to a very disagreeable fetor. A loaded saburral condition 
of the alimentary canal is also sometimes observed at the time, or 
after the attack. The most remarkable condition of the bowels, 
as before remarked, is the great accumulation of gas, which dis- 
tends them painfully. The head is not remarkably affected in the 
early part of the course of the disease as a general thing, but is 
very apt to become affected later. 

Headache, delirium, and restlessness, however, sometimes begin 
with the attack, and even usher it in. But delirium is more 
common toward the close of fatal cases when the general powers 
of the system are failing. The delirium is usually a mild, con- 
stant muttering, instead of the boisterous and violent kind. Again, 
there is occasionally melancholy and suicidal tendency. The skin 
is seldom dry and hot throughout the course of the disease ; it is 
much more frequently moist, and in some cases it is bathed in a 
copious watery perspiration, that is almost constantly present ; at 
other times it occurs only at night. The urine is generally scanty 
and high-colored, sometimes bloody, often thick and muddy with 
sediment and mucus. The milk, if it has made its appearance, 
becomes entirely suppressed, and the breasts become flabby, as 
though the milk was absorbed. The lochia is not often suppressed ; 
it frequently continues the same in quantity and quality with its 
normal condition under ordinary circumstances at the same period 
after delivery. Occasionally it is rendered scanty and even sup- 
pressed ; more frequently it is fetid and offensive. 

After these symptoms are established, they usually increase in 
intensity. The pulse becomes so frequent as to be scarcely nu- 



576 PUERPERAL METRO-PERITONITIS. 

merable and weaker ; the abdomen is greatly swollen, being larger 
than before confinement, very tender and sonorous to the slightest 
tap of the finger ; the mind wanders, and at length becomes com- 
pletely clouded ; the patient picks at her person in bed ; the ex- 
tremities first become cool and then cold ; the respiration is hur- 
ried on account of the great abdominal distension ; and in two to 
four days the patient dies. If, however, the disease is less over- 
whelming, the symptoms continue severe, keeping the patient for 
a number of days in a state of great suffering and doubt, until 
they gradually begin to decline, and a tedious convalescence en- 
sues ; or the force of the constitution breaks down, and the patient 
is exhausted and worn out, and dies after suffering from one to 
many weeks. Sometimes, after the first five or six days, the fever 
assumes something of a hectic character ; remissions and exacer- 
bations of a very distinct nature occur once or twice in twenty- 
four hours ; some particular part of the abdominal walls becomes 
very tender and distinctly swollen ; a livid patch appears ; the 
place finally ruptures, and a discharge of pus follows after several 
weeks of almost mortal fever, and the disease gradually subsides. 
At other times the eruption of pus takes place into the vagina or 
rectum, and it is voided, to the great relief of the sufferer. These 
large abscesses sometimes continue to discharge until the patient 
is exhausted, from the great amount of pus evacuated, and the 
long time required for the closure of the sac. The iliac regions 
are the most common seat of these purulent collections. 

Diagnosis. — It is only in the early stages that there is danger 
of mistaking any other disease for puerperal metro-peritonitis and 
the converse ; but then, as this is the time when a correct diag- 
nosis is of most importance, we should, if possible, have clear 
ideas with reference to it. The four main items in the diagnosis 
are pain, tenderness, fever, and tympanitic distension ; and when 
present all together, may be regarded as sufficient under the cir- 
cumstances to decide the nature of the case. In the very begin- 
ning, however, some of these symptoms are either entirely absent 
or imperfectly developed, but there is almost invariably sufficient 
of them and agreement among them, together with the history, to 
be quite conclusive. And one part of the history is the prevalence 
of the disease. It is true this is not always available, but it very 
often is. It is distinguishable from after-pains by the absence in 



PROGNOSIS. 577 

them of tenderness and rapid pulse and distension, and then the 
after-pains are intermittent, wholly or nearly. ,In peritoneal in- 
flammation the pain may be exacerbating but not entirely par- 
oxysmal ; in the after-pain it occasionally entirely ceases. In 
milk fever there is not any marked pain and tenderness in the 
hypogastric and iliac regions, but a swollen and tender condition 
of the mammae, and a greater amount of heat, headache, bone- 
ache, &c. In fact, the fever is highly exaggerated in intensity 
compared to the amount of local trouble, and this is in the breast. 
Puerperal peritonitis seldom begins with greaj fever properly; the 
pulse is very quick, but the surface is not correspondingly hot and 
florid, nor are the pains in the limbs apt to be great, but the pain 
in the back is ordinarily quite severe. 

Another condition that will occasionally perplex the inexperi- 
enced practitioner, is the great tympanic distension sometimes ob- 
served to occur a few hours after a severe protracted labor. The 
first case I met with was in an unmarried woman, aged thirty-five, 
confined with her first child. She had been in labor over twenty- 
four hours, when I was called to operate with forceps after the 
pains had almost entirely ceased, the extremities cold, and pulse 
beating at 120, from exhaustion. In ten hours after delivery, the 
abdomen was enlarged to the size it was before the confinement, 
from gas in the intestines. I remarked that I could see the con- 
volutions of the colon. There was no pain or tenderness, and the 
pulse had dropped down to 100 in the minute. This patient re- 
covered very kindly with nothing but stupes of warm camphor. 
The distension in this case was too early and excessive, unattended 
with very quick pulse, or pain. I have met with several similar 
cases that terminated equally well. 

Pi*ognosis. — This is essentially unfavorable. Statistics fearfully 
verify this assertion, and yet there are none that I regard as suffi- 
ciently reliable on which to base an average of mortality. But if 
we examine the subject somewhat in detail, we find that many 
circumstances qualify the prognosis. The same influence that 
exerts itself, and is recognizable in stamping the character of the 
disease, must be taken into consideration in forming our opinion 
as to the termination of any given case. The sporadic form is 
generally milder than the epidemic variety, and it will be, proba- 
bly, more profitable to consider them somewhat apart, bearing in 

37 



578 PUERPERAL METRO-PERITONITIS. 

mind that what is said of the import of the difference in intensity 
of the symptoms in the sporadic, is quite as applicable to the epi- 
demic disease. As a general rule, the earlier a patient is attacked 
after labor, the more rapidly disastrous the course of the disease. 
It follows almost necessarily, that when the onset dates anterior 
to delivery, the attack is severe ; and I cannot now call to mind 
an instance of this kind under my own observation that has not 
proved fatal in a very short time. The symptom upon which, 
above all others, our reliance is justifiable for correct prognosis, is 
the rapidity of the pulse. When the pulse does not range above 
120 strokes in the minute, we hope, with much reason, for recovery; 
on the contrary, a pulse that ranges above 140 in the minute for 
a great part of the time, indicates great danger ; and the more 
rapid the pulse, the more hazardous the case. We habitually, 
also, rely upon the pulse as the best indication of the effects of our 
remedies. Next to the pulse, the disturbance in the nervous sys- 
tem affords us the clearest insight into the ravages of the disease. 
Delirium, jactitation, restlessness, or aimless change of position, 
or desire to be removed from one bed, or one room, to another, 
indicate great danger. The sympathies of the stomach are justly 
regarded as indicative of certain tendencies. Nausea and vomit- 
ing, particularly the latter, and the more so if the ejections are 
vitiated, instead of the superabundant natural secretions, are se- 
rious complications, as well as indications of evil. Diarrhoea su- 
pervening in the early part of the attack, or before the beginning 
of the other symptoms, is not equally as unfavorable a symptom, 
but renders the case more dangerous than if it did not exist. It 
is sometimes regarded as critically favorable, when it does not ap- 
pear until some days after the disease is established. In either 
case, our judgment must be influenced by the character of the de- 
jections. The more vitiated, fetid, or otherwise morbid, the worse 
the prognosis. There is a class of rapidly fatal cases in which, so 
far as the heat of the body and extremities is concerned, reaction 
is imperfect. The feet or hands, or both feet and hands, remain 
below the natural temperature in these, and are generally moist, 
and sometimes bathed in a profuse perspiration. I ought to have 
mentioned that entire indifference to the child, or absence of af- 
fectionate manifestations, is also unfavorable. Copious secretion 



TREATxMENT. 579 

of urine, continuance of the lacteal secretion, and warm natural 
perspirations, may be regarded as favorable signs. 

The first thing to be remarked with reference to epidemics is, 
that they are, as a rule, more fatal than the sporadic disease. 
Each epidemic must be judged apart, some of them being much 
more fatal than others. Another remark is, that the beginning of 
an epidemic is almost invariably attended with a greater number 
of fatal cases proportionately. This is so true, that we often find 
ourselves flattered with the opinion that we have discovered a 
course of treatment that will avail us in future, because of our 
greater success ; while we also indulge in regrets that we had not 
fallen on the happy course of treatment earlier in the prevalence 
of the scourge, when, in truth, our greater number of cures result 
from the change in the intensity of the disease, instead of our own 
improvement. The fearful mortality which sometimes attends this 
disease when it prevails epidemically, may be realized by reading 
that in those occurring in Paris in 1746, in Edinburgh in 1773, 
and in Vienna in 1795, all the patients attacked died. This is too 
dreadful an account of the effects of this disease to represent the 
prognosis of puerperal peritonitis now. So far as I can judge, 
from my facilities for comparing recently recorded facts and my 
own limited experience, I should feel that I had pretty closely 
approximated the results in epidemic puerperal peritonitis, when 
I set down its average mortality at sixty-six and two-thirds per 
cent, of cases. Even this is scarcely paralleled by any other 
disease. 

Treatment. — A very important part of the treatment of puer- 
peral peritonitis is prophylactic, or preventive; and as epidemic 
influence constitutes the principal and efficient cause in many 
instances, it should be our object, 1st, to avoid it; and, 2dly, when 
we cannot do this, as nearly as possible to counteract it. Proba- 
bly the only way to fulfil the requisitions of the first proposition 
is, to remove our patient entirely beyond the infected district. We 
can, I think, more effectually and certainly accomplish this with 
pregnant women, than patients predisposed to attacks of any other 
form of epidemic disease, for we know precisely when to expect 
an attack of puerperal peritonitis, and, fortunately, we can know 
this for weeks, nay, even months, beforehand. The woman will 
not be attacked until she is delivered. When any other epidemic 



580 PUERPERAL METRO-PERITONITIS. 

prevails in a community, everybody is liable to it at all times ; 
every sacrifice ought, therefore, to be made to send our patient, 
several weeks before the expected confinement, entirely beyond 
the region endangered, and allow her to remain there until the 
circumstances which render her susceptible have passed away. 

There is no doubt but this prevention would neutralize the mor- 
bid tendency that ends in the death of many patients. If a hos- 
pital is the field of devastation, it should be shut against such 
patients, of course ; and if the disease is scourging a city, or 
county, the lying-in woman should leave her home, with all its 
dangers, for some distant but healthy neighborhood. This is 
almost always practicable. 

It may be said that the fleeing patient will transport to her 
place of retreat the dangers she endeavors to shun, and serve as 
a focus of a new epidemic. There is no certainty of a pregnant 
woman being capable of an epidemic morbific impression, at least 
as a general rule ; and if she were, several weeks' residence away 
from the causes of such impression would enable her to free her- 
self from it. Nor is it probable that she would impart such im- 
pression to a person outside of the field where the general cause 
of the disease exists. When we cannot comply with this prophy- 
lactic measure, we must next protect our patient as effectually as 
may be from the* action of the epidemic influence. Every hygienic 
measure within our control should be attended to. Good ventila- 
tion is, perhaps, of all hygienic means, the most effective. The 
room should not only be large and airy, but the air must be changed 
frequently, and the temperature should be low, — the rooms of 
lying-in women are generally too hot, — nor should the patient be 
kept too warm. A cheerful quiet should be maintained in the 
presence of the patient. Absolute isolation from friends is not 
desirable, but the patient should not see any person in whose pres- 
ence she feels the least restraint. She may, and ought to, see 
and converse with her own family, — such members of it as are old 
enough to behave themselves sedately. No excitement is allow- 
able, produced by gossip or improper reading. 

When we have reason to fear an attack of peritonitis, our sus- 
picions should find no utterance save in such proper care and 
attention as the patient needs, and will not lead to apprehension. 
A nourishing, but bland and unstimulating diet, will be most appro- 



TREATMENT. 581 

priate. In fact, the surroundings of the patient should be the 
best hygienic circumstances that she can command. While there 
can be no question of the propriety of hygienic prophylactics, 
there is some doubt as to the necessity or benefit of drugs. Can 
we give any medicine that may render the attack less certain ? I 
am persuaded that the strong cathartic — calomel and jalap — rec- 
ommended and administered by Hay and Gordon, should be ad- 
ministered with much caution. Where diarrhoea is the tendency, 
as is not unfrequently the case, I think they may do harm ; and, 
as Mr. Hay says, some of the worst cases he ever had commenced 
after the operation of the cathartics. Yet when constipation has 
preceded delivery, we may, with great propriety, give a gentle 
laxative of calomel, grs. iv, to be followed by a saline, if it does 
not operate in ten hours. I am not aware that opium has been 
recommended as a preventive ; there is probably more promise in 
it than any other medicine as a preventive measure. Experience, 
however, and not theory, must be allowed to determine this ques- 
tion. I need say but little about the preventive effects of emetics; 
I think they should not be thought of. The main co-operating 
causes, contagion or infection, should be guarded against in every 
possible way. Friends or nurses, who have been in the presence 
of the disease, should be sedulously excluded from the entire prem- 
ises, — not merely from the room of the patient, but from the 
house, for several days before and after the accouchement. Dur- 
ing epidemics, the medical man should observe every precaution to 
avoid spreading the disease among susceptible patients. He should 
be in the room of the patient no more than is necessary to do his 
duty towards her. If he has been exposed to the disease, he 
ought not to risk contaminating the atmosphere of the room unnec- 
essarily with his breath ; and during the time he occupies it ven- 
tilation should be as free as possible. And when attending upon 
puerperal peritonitis, he ought to avoid much contact with the 
person and bedding of the patient, for fear of making himself the 
nucleus of contagion. When he is in such attendance, or after 
having been engaged in treating erysipelas, gangrene, &c, he 
should always wash his hands, as recommended by Prof. Meigs, in 
warm water, immediately before approaching his parturient pa- 
tient. It will add to the safety, also, if he wash his hands in a 



582 PUERPERAL METRO-PERITONITIS. 

solution of chloride of lime, as recommended by Semelmeir. Au- 
topsies by accoucheurs in active business should be done by proxy. 
Curative Treatment. — I hope I will be excused for emphasizing 
the fact that there are two circumstances indispensable to the suc- 
cess of any remedial course in this disease. The first is, that the 
treatment must be instituted as soon as possible after the attack, 
when practicable contemporaneously with it; and the second, that 
an immediate and poiverful impression must be produced by it. 
If either of these circumstances is wanting, the objects of treat- 
ment will not be accomplished. In order to understand the grounds 
upon which this pointed statement rests, we must remember that 
in a few hours all the damages resulting from the overwhelming 
power of the disease are done, and that after the lapse of these few 
hours our only office is to aid the system in the repair of them, and 
the curative means, so appropriate and effective in the early part, 
become prejudicial. Let me make myself understood. The con- 
trol of the excessive excitement of the first twenty-four hours by 
powerful means prevents the damage that would otherwise occur. 
Should these means be used after the damages are sustained, and 
the powers of the patient very much exhausted, their only effect 
would be to increase the prostration. Then the treatment must be 
palliative and sustaining, upholding the powers of the patient 
until convalescence results from the subsidence, and not interrup- 
tion of the course of the disease. Whatever is effected in the way 
of a cure must be done generally in the first twelve hours after the 
attack. There are but very few remedies sufficiently prompt and 
powerful in their action to accomplish these results, probably but 
one, — venesection. Medicines or medicated appliances require to 
be administered several hours before their impression is complete, 
with the exception alone of an emetic. And I have no doubt, from 
the testimony now on record, that on account of its prompt and 
powerful effect at the very beginning of the attack, an emetic often 
entirely interrupts the disease; but I am equally certain that in 
six hours after the establishing of the inflammation, its effects are 
scarcely if at all useful. It may be regarded, however, before this 
time as useful; as injurious after it. I think, as is here said, that 
we may regard bleeding and emetics as the only remedies capable 
of interrupting the disease. The advocates for the use of these 
remedies contend that they stop the advance of the inflammation. 



CURATIVE TREATMENT. 583 

The opponents to venesection do not claim that their course of 
treatment will break up the disease; indeed, they generally con- 
tend that it cannot be done by any means. Their main objects 
are to moderate the violence of it, and conduct it through a course, 
when it terminates in recovery, to a favorable end. And what is 
curious, there is no attempt to collect statistics of epidemics of 
metro-peritonitis, so clearly described as to leave no doubts of their 
character, treated in any other way but by venesection, so dis- 
couraging are the results of every other kind of treatment. There 
are general statements of them, but no well-arranged tables of 
statistics that I have seen. Perhaps I ought to except the records 
of Prof. Alonzo Clark and Fordyce Barker, of New York City, 
in favor of opium and verat. virid. In making this statement, I 
freely confess that my opportunities for extensive literary research 
in this direction are limited. As I have very little confidence in 
statistics made up by collecting cases from all sources, I do not 
wish to lay much stress upon this fact, but it may, to a certain 
extent, indicate the inefficiency of treatment not interruptive in 
its character. I am not fully convinced, but think it probable, 
that epidemics of this disease prevail of so strongly an asthenic 
grade that depletion is not applicable at any time, even in the in- 
ception of the disease, but I am fully convinced that in this class 
of cases there must be less hope than any other of doing good by 
any course of treatment whatever. Dr. Gooch attempts to draw 
a distinction between sthenic and asthenic epidemics, and after 
speaking of the symptomatic indications, gives us the very judi- 
cious advice to determine the question by treatment, making gen_ 
eral bleeding the test. If bleeding did manifest good, it is to 
determine our course in favor of vigorous antiphlogistics ; if not, 
this must be abandoned for an opposite course of treatment. This 
is probably the best advice that can be given, provided we meet 
with the opportunity of bleeding at the beginning, and judging of 
its results only in such cases. Otherwise, for reasons above stated, 
the test would not be fair. I think the most difference of opinion 
as to the nature and treatment of this disease arises from the mode 
of using remedies for the cure of it. We must remember that the 
time, quantity, mode of drawing blood, and position of the patient, 
are everything in the application of venesection. To be a test of 
the nature of a disease, it must be used at first before the affection 



584 PUERPERAL METRO-PERITONITIS. 

has resulted in its consequences ; with the patient in the sitting 
posture, the stream must he as large as the vein will allow, and 
until there is an approach to syncope, and as soon as reaction oc- 
curs, repeat it. This is the way we must proceed when we deter- 
mine to bleed for metro-peritonitis ; and I should advise the student 
to pursue this course if he is called in less than twelve hours from 
the beginning of the attack ; to abstain from it altogether if it is 
later than twelve hours, and not to expect with much confidence 
to cure his patient if the twelfth hour has elapsed, but to build 
strong hopes upon an immediate beginning. When it is remem- 
bered that so early an application of remedies is not frequently 
practicable, it will be seen that venesection does not often have a 
perfectly fair trial. When an epidemic is raging, and the people 
alarmed, they are more likely to summon the physician early, and 
this duty ought to be emphatically enjoined when we can do so. I 
have stated the time for effective efforts to break up the progress 
of the disease to be twelve hours after the beginning, but there are 
doubtless cases in which bleeding might be effective after the lapse 
of double that time, and to a certain extent we may judge of such 
cases by the pulse, temperature, strength of the patient, and epi- 
demic constitution of the season. On the contrary, there cer- 
tainly are cases in which fatal damage is done in much less than 
twelve hours. Of these we may likewise form an opinion from the 
same conditions. Should we be called in time and bleed, we may 
immediately afterwards use other remedies to further the patient 
toward convalescence. If there is no diarrhoea, I should be in 
favor of an active cathartic. Hyd. mit. chl., grs. x, and pul. ja- 
lapa, grs. xv, mix, and take at once. If this does not operate in 
six hours, administer enough sul. mag. to produce brisk catharsis. 
A linseed mush poultice, large enough to cover the whole abdomen, 
should be immediately applied ; also renewed as often as every four 
hours. At the same time, or immediately after the cathartic is 
taken, we ought to give the patient ten drops of tinct. verat. 
virid. This last may be repeated in doses of four drops every 
hour, until the pulse is reduced in frequency to at least below the 
normal numbers. So soon as this reduction of the pulse is effected, 
we must lessen the dose of the tincture to two drops, or even one, 
every hour, increasing the quantity as much as necessary when- 
ever the action of the heart and arteries is increased. All this 



CURATIVE TREATMENT. 585 

cannot be done without personal supervision from the attendant 
or well-educated medical assistants, instructed with special refer- 
ence to the case in hand. After the cathartic has operated thor- 
oughly, it will be well to resort to the free use of opium, com- 
bined with small doses of calomel. Three grains of the former 
with one of the latter every four hours is a good combination. 
When diarrhoea exists at the beginning, we may omit the ca- 
thartic, and at once begin the use of calomel and opium. These 
two may be given until the specific effect of mercury to a slight 
but obvious degree has been brought about, when, unless the dis- 
ease is rapidly subsiding, the calomel should be withdrawn, and the 
opium continued. If tht patient is much better, the opium may 
be given in diminished doses, and soon entirely omitted. With 
reference to the use of opium in peritonitis, I shall have more to 
say further on, and I will merely add now, that these closes of 
opium are more likely to be too small than too large. 

If we are not called soon enough to be justified in the venesec- 
tion, we may, with great propriety, institute the same treatment 
with that exception. After we are convinced from sufficient careful 
observation and trial that bleeding is not profitable in the epidemic 
with which we are engaged, I should strongly advise an emetic at 
the very instant of the appearance of the first symptoms. The 
emetic may be left in the hands of an intelligent monthly nurse, 
after instructing her with reference to the symptoms. 3ij of pul. 
ipecac may be put in a teacupful of warm water, and half of it ad- 
ministered at once. If emesis does not take place in thirty min- 
utes, the other half should be given. Good ipecac in these doses 
will pretty certainly act, and it is a grateful consideration that we 
have a remedy so prompt and powerful in action. Its impression 
is perfect in thirty or forty minutes from the time it is given. I 
do not partake of the fears expressed by some physicians as to the 
effects of succussion upon the abdominal organs, and would not 
hesitate to give the emetic at once. So soon as the effects of it 
have pretty well passed off, we may institute the course of treat- 
ment above recommended to be used after it. 

Dr. Fordyce Barker, of New York, has very ably and judi- 
ciously dwelt upon the mode of administering and great efficacy 
of verat. viride in puerperal fever, in a discussion before the New 
York Academy of Medical Science. It will pay the student to 



586 PUERPERAL METRO-PERITONITIS. 

carefully read and weigh his suggestions. Alas ! no matter how 
sound in his views, prompt and energetic in action the practitioner 
may be, he seldom has an opportunity to effectually try the reme- 
dial course I have recommended. He is called after the stage of 
sthenic activity is passed, and is confronted by'conditions of great 
damage to the tissues and vital powers. In such cases he is not to 
be idle; much may yet be done, at least sometimes. These are 
the circumstances in which the stimulating, supporting, and sooth- 
ing plan of treatment, so highly recommended but generally un- 
successful as the treatment for puerperal fever, is applicable. I 
need not specify at any great length the mode and means of con- 
ducting this course. The degree of prostration, nervous and vas- 
cular, will readily suggest to the intelligent practitioner all that is 
necessary. Quinia, wine, brandy, carb. ammon., camphor, cap- 
sicum, cantharides, opium, and turpentine, under certain circum- 
stances, are indicated and beneficial. The terrible rapidity and 
overwhelming power of the disease require corresponding prompt- 
ness, energy, and skill, successfully to combat it after it has 
passed — if I may be allowed the expression — victoriously through 
the stage of activity, and laid prostrate every conservative energy 
of the system. We must administer these remedies' in such way 
as to have the greatest possible effect, and persistently maintain 
it until there are indications of a return to activity and integrity 
of function. We should, in addition to the medicinal support thus 
given to the patient, furnish her with as much nutrition as pos- 
sible. Essences of beef, strong broths, milk punch, egg-nog, wine- 
whey, &c, will be the chief articles of this sort, 'combining as they 
do stimulants and nutrition. In concluding what I have to say on 
the treatment of puerperal peritonitis, I think I shall add much 
value to the subject by quoting a summary given by Prof. Alonzo 
Clark, of New York, to Dr. Keating, the editor of "Ramsbotham's 
System of Obstetrics," of his observations on the use of opium in 
this disease. It commences on page 534 of the last edition of that 
valuable work. 

"Puerperal peritonitis has frequently visited the lying-in wards 
of Bellevue Hospital during the last twenty years, and the recov- 
ery of those who have been attacked by it, up to the winter of 
1851-52, was the exception rather than the rule. Having acquired 



CURATIVE TREATMENT. 587 

great confidence in the efficacy of large doses of opium in simple 
peritonitis, when the puerperal form of the disease made its ap- 
pearance, in December, 1851, I resolved to try its virtues in this 
more formidable affection. 

"My first attempt was a complete failure. The house physi- 
cian did not fully comprehend my views; and though the patient 
took three grains of opium for the first dose, the prescriptions for 
the succeeding twenty-four hours were no more unsuccessful than 
inefficient. 

" Three other women were attacked in rapid succession, two 
within twenty-four hours of the first, — severally, two, ten, and 
three days after labor. The following case will give a good idea 
of the treatment of all. It will illustrate at once the efficacy and 
the dangers of administering opium in heroic doses. It will be 
seen that the medicine was given at first somewhat timidly, after- 
wards more boldly. We did not know our ground, and every new 
case must be an experiment, so far as the susceptibility to the 
effects of opium is concerned. 

"Case. — Anna N , aged 20 years, married, was delivered 

of her first child October 1st, 1851. The labor was natural, and 
of usual duration. Convalescence was not attended by any un- 
toward symptom, except a slight diarrhoea. She was, however, 
of delicate constitution, having an hereditary tendency to phthisis, 
and had been under treatment for cough the previous five months. 
On the tenth day after confinement, she was seized with a chill at 
10 o'clock a.m. The chill lasted an hour. The abdomen was 
markedly tympanitic, extremely tender, and the seat of lancinat- 
ing pains, which caused sobbing; pulse 120; respirations thoracic; 
tongue clean. Ordered solution of sulph. morph. (gr. xvi to foj 
of water) rr^x every hour. She slept most of the day and succeed- 
ing night quietly, but not profoundly. 

"2d day, 10 o'clock. Tympanitis increased; tenderness some- 
what diminished ; extreme thirst ; occasional vomiting of a bright 
green fluid ; bowels quiet ; lochia had ceased previous to attack ; 
pulse 120. Other symptoms as before. It was obvious that not 
much impression had been made on the disease in the first twenty- 
four hours, and the solution was given tt#x every half hour. This 
produced deep sleep, and by evening the pulse had fallen to 90. 

"3d day. Tympanitis and thirst continue; retention of urine; 



588 PUERPERAL METRO-PERITONITIS. 

intellect rather obtuse. Other symptoms as before. The morph. 
sol. was now increased to tt^xxx every hour. These doses were 
continued from noon till 6 or 7 o'clock in the evening, when the 
signs of narcotism became rather alarming. She slept heavily ; 
was roused with difficulty ; would not reply to questions ; pupil 
contracted almost to a point ; pulse 68, and respiration 7 in the 
minute. The opiate suspended, and tablespoonful-doses of strong 
coffee administered. The narcotism continued for six or seven 
hours, and gradually subsided. 

"4th day. Tympanitis diminished; tenderness markedly less ; 
features composed ; intellect rather dull ; pulse 78 ; tongue dry 
in the centre ; green vomiting occasionally ; slight hysterical symp- 
toms; respiration 15. Morph. sol. resumed, trgx every half hour. 
Narcotism recurred at about the same hour as last evening, in 
which the sleep was very profound, and the respiration only 5 in 
the minute. Treatment as on the previous evening. Towards 
morning these unpleasant effects of the medicine passed off. 

"5th day. The disease was subdued. The tongue was dry and 
slightly brown, but the patient declares that she feels quite well ; 
tympanitis has nearly disappeared; no pain or tenderness; pulse 
80, and respiration 15 ; some appetite. She complains of nothing 
but thirst, and inconvenience from retention of urine (the latter 
relieved by catheter, as before). At 11 A. M., morph. sol. resumed, 
rrgx every two hours. At night, wakefulness, and pain in the ab- 
domen, and the prescription was changed for opium, gr. iij every 
hour, under the influence of which she slept quietly. 

"6th day. Sleeps most of the time; easily roused, but answers 
questions slowly, and with an effort; tongue moist and not furred; 
tenderness, that recurred last night, less ; pulse 80 ; still vomits 
green fluid. Treatment continued. 

"7th day. Symptoms all improved ; opium, gr. j, every hour. 
" 8th day. Abdomen soft, and free from pain or tenderness ; 
thirst slight ; she says, <I fe'el so much better.' She was decidedly 
convalescent. From this time the opium was continued in gradu- 
ally diminished doses. The bowels were not opened till the thir- 
teenth day ; a dose of calomel, followed by castor oil, having been 
previously given. After this, all medical treatment was discon- 
tinued, and she was discharged in a few days in her usual health. 
"The relief experienced after the narcotism of the third day 



CURATIVE TREATMENT. 589 

had passed off, was very striking, and inspired us with confidence 
in the curative virtues of the medicine. Still more did that of the 
fourth day. But these occurrences also taught us how short is the 
distance between such extinction of disease and the extinction of 
life. It will, however, be borne in mind that we were feeling our 
way through thick darkness, that experience had not informed us 
what degree of narcotism was necessary to subdue the inflamma- 
tion, or to what extent it could be carried with safety to life. 

" Two other cases were under treatment at the same time. 
Neither of these were affected to anything like the same extent by 
the opium, yet both took a larger quantity of the drug, and one 
very much larger doses. The first took gr. ij, then gr. j, the hour; 
on the second day, one-third of a grain of sulph. morph. (in solu- 
tion) every half hour ; the fourth day, opium gr. iv every hour ; 
fifth and sixth days, the same, or part of the time half a grain of 
sulph. morph. every half hour ; making, for the first day, 25 grains 
of opium ; for the second and third, each 8 grains of sulph. morph. ; 
for the fourth, 96 grains of opium ; for the fifth and sixth, each 
24 grains of sulph. morph. No narcotism in the least degree 
alarming was induced by these doses, but the symptoms of the 
disease have markedly diminished, and by the seventh day the 
hourly doses were gradually reduced. 

" The other took what appeared to me, then, surprising doses, 
and yet had no deep narcotism. She was seized on the 13th. She 
took at first J gr. sulph. morphia, and in the evening of the same 
day, gr. j every hour, or about 20 gr. sulph. morph. in all. The 
second day, IJ gr. an hour, or gr. xxxij ; and this dose, or gr. vj 
of opium, was continued for several days. The quantity was even 
increased in this case to gr. xij of opium the hour, for many suc- 
cessive hours, without marked narcotism. 

" As I have said, then, these recovered. When it was apparent, 
on the 10th and 11th, that puerperal fever, as it was called, had 
attacked three patients in one ward of ten beds, during twenty- 
four hours, no time was lost in removing the well from the sick, 
and in taking every possible precaution to prevent the spread of 
the disease. Except the case that began on the 18th, no other 
occurred in the Institution till the 3d of December. The symp- 
toms in this case were so masked that the nature of the affection 
was not recognized till the third day, and then the disease had 



590 PUERPERAL METRO-PERITONITIS. 

made such progress that all medication was believed to be hope- 
less. The opium treatment was faithfully but unsuccessfully tried. 

"Precisely the same words may be used to sum up the sixth 
case, which occurred on the 17th of the same month. 

" The seventh case, December 26th, recovered. 

" The eighth, December 29th, died ; and after death it was found 
t that the peritonitis was inconsiderable, but that the principal dis- 
ease was purulent metritis. 

" The ninth, January 4th, 1852, recovered. 

" The tenth, January 9th, recovered. 

" The eleventh, January 16th, died. Post-mortem examination 
revealed but slight evidences of peritonitis; but, as in case eight, 
the chief disease was found to be purulent metritis. 

" The twelfth case, March 25th, was also one of purulent metri- 
tis, with slight peritonitis. The treatment had no influence on the 
progress of the leading disease. Patient died. 

" The thirteenth case, March 29th, recovered. 

" The fourteenth, occurring also March 29th, recovered. 

" Of these fourteen cases, it will be seen that six died and eight 
recovered. The result stated in this way will hardly appear a 
triumph to any but those engaged in hospital practice. Yet it is 
a great improvement on the results of treatment in the preceding 
years at Bellevue. I have known in one season thirty women at- 
tacked, of whom only one recovered ; and in general, the recoveries 
have not been more than one in five. But when these fourteen 
cases are examined, it will be found that the first was not treated 
with large doses of opium, and should be thrown out of the account 
entirely; that on the fifth and sixth the treatment was not com- 
menced till the third day (when, I may add, Dr. Foster, my col- 
league, agreed with me that all treatment was hopeless) ; that the 
eighth, eleventh, and twelfth, were cases of purulent metritis, and 
died more from pysemia than from the ordinary effects of inflam- 
mation. We have eight cases left, in whom a leading element of 
the disease was peritonitis, but not without the symptoms of metri- 
tis in some, — as the examination of the recorded cases in my pos- 
session will show, and in whom the treatment was commenced on 
the first day, — none of whom died. 

" These were all the cases that occurred in the hospital from 
October to April. But during this period I saw seven other cases 



CURATIVE TREATMENT. 591 

in consultation with Drs. Grilman, Rockwill, Higgins, McLaury, 
Smith, and others, six of whom recovered, and the seventh died 
of uterine hemorrhage while convalescent from the puerperal peri- 
tonitis. 

" In reviewing the cases of which an outline is given above, I 
think the following conclusions are justifiable : 

" 1st. When a prominent element in ' puerperal fever' is peri- 
tonitis, the treatment with large doses of opium is more successful 
than any other that has yet been proposed. 

" 2d. To be successful, this treatment must be commenced early, 
and the patient must be brought under its influence as rapidly as 
the susceptibility of the system can be ascertained by trial. 

" 3d. The quantity of opium required to produce a safe but de- 
sirable degree of narcotism varies greatly in different cases, so 
that it is necessary to begin with doses that cannot do mischief, 
and increase every two hours till the influence of the opiate is 
sufficiently decided. 

"4th. Every dose, during at least the whole tentative period, 
should be administered by the physician himself, or by some per- 
son on whose knowledge of the effects of opium and whose watch- 
fulness and discretion he can rely. Some young physicians are 
too bold, and endanger the life of the patient ; others are too timid, 
and do not control the disease. 

"5th. The opium treatment alone will not cure 'puerperal 
fever' when its leading element is purulent metritis, though there 
is reason to believe that it will control and even prevent the peri- 
tonitis which generally accompanies it. This conclusion has been 
confirmed by recent observations. 

"6th. The tolerance of opium in some cases of puerperal peri- 
tonitis almost surpasses belief. Yet in private practice I have not 
found more than half or two-thirds of a grain of sulph. morph., 
every two hours, necessary, and have generally begun with less, 
except for the first dose. 

" 7th. The influence of the opium should be kept up till the 
pain and tenderness subside, the tympanitis diminishes in some 
degree, and the pulse falls below 100 ; then, with the concurrence 
of other symptoms, it should be gradually diminished, and at 
length discontinued. 



592 PUERPERAL METRO-PERITONITIS. 

" A few remarks and statements may be needed to make some 
of these conclusions intelligible. 

" The usual effects of opium given in efficient doses for the cure 
of this disease are, a disposition to sleep, but not profoundly ; a 
contracted pupil ; perspiration, often profuse ; sometimes a red, 
blotchy eruption ; diminished frequency of the respiration ; sub- 
sidence of pain and tenderness ; slight suffusion of the eyes ; and, 
after a variable time, reduced frequency of pulse. Of these effects, 
three have been chiefly regarded as criteria by which each par- 
ticular dose .is to be governed. If, when a dose is due, the sleep 
is profound (the amount of sleep is of little importance if the 
patient is easily roused from it), there is reason to hesitate : if the 
respiration has already been reduced to twelve in the minute, and 
is very irregular and sighing, the dose should be diminished or 
wholly withheld ; yet so long as the tenderness continues, it is de- 
sirable to urge the opiate, but, of course, always within the limits 
of safety. 

" The respiration appears to be the most certain indication of 
danger. I have not generally aimed to reduce it below 12 the 
minute. Yet in almost every case it has fallen, once or twice in 
the course of the treatment, as low as 7, and sometimes to 5. In 
no instance, however, has the narcotism, taken as a whole, been 
so profound as in the case detailed above. No instance of fatal 
narcotism has yet occurred under my observation, nor among the 
many cases reported to me by others. 

" Regarding the tolerance of opiates in some of these cases, — at 
the risk of being charged with rashness and trifling with human 
life, — I will make some extracts from Case 7. The treatment was 
commenced at 10 a.m. on the 26th of December, — two grains of 
opium hourly. At 2 P.M., no change in symptoms ; dose increased 
to gr. iv. At 3, gr. iv. At 4, gr. v. At 5, gr. v. At 6, gr. viij. 
At 8, gr. x. At 9, gr. xij. At 11, sol. morph. sulph. (16 gr. to 
foj) ojss. At 12, 5j- At 1J a.m. (respiration 6), 0. At 6 a.m. 
(respiration 12), opium gr. xij. At 10, sol. 5j- At 12 m., opium 
gr. xij. At 1J p.m., sol. 5ij. At 2J, 5ij- At 3}, opium gr. xxiv. 
At 5, gr. xij. At 6 J, sol. 5\jss. At 7 J, 5ij. At 9, opium gr. 
xiv. At 10, gr. xvj. At U, gr. xviij. 28th, at 1 a.m., sol. 5\jss. 
At 2, 5iy. At 3J, opium gr. xx. At 4, sol. 5ijss. At 5, 5iij- 
At 6, 3iijss. At 6 J, opium gr. x. At 7, sol. 5iijss. At 8, opium 



CURATIVE TREATMENT. 593 

gr. xxij. At 9|, sol. 5ix. At 10, 5uj. At 11J, 5iij. At 12, 0. 
Thus, this woman took in the first 26 hours of her treatment opium 
gr. lxviij, and sulph. morph. gr. vij ; or, counting one grain of 
sulph. morph. as four grains of opium, one hundred and six (106) 
grains of opium. In the second 24 hours, she took opium gr. 
cxlviij and sulph. morph. gr. lxxxj, or opium four hundred and 
seventy-two (472) grains. On the third day, she took 236 grains. 
On the fourth, 120 grains. On the fifth, 54 grains. On the sixth, 
22 grains. On the seventh day, 8 grains ; after which the treat- 
ment was wholly suspended. This woman was not addicted to 
drinking, and after her recovery she assured me repeatedly that 
she did not know opium by sight, and had never taken it or any 
of its preparations, unless it had been prescribed by a physician. 
This is, perhaps, 'horrible dosing,' and only justifiable as an ex- 
periment on a desperate disease. Yet this woman is alive to tell 
her story, as are several others who took surprising quantities of 
this drug. But later observations have shown that the tenth to 
the twentieth part of this maximum is efficient in controlling the 
disease. So this case is referred to, not for imitation, but because, 
with similar cases, it is a medical curiosity, and may, perhaps, 
open some new therapeutical views. 

"The results of the opium treatment in the hands of my pro- 
fessional friends in this city have not been uniformly successful. 
This was to have been expected. "When the path to success is so 
narrow and so little trodden, though beset with dangers on both 
sides, it is unavoidable that many will lose it. But I believe I am 
authorized in saying that those who have seen most of this mode 
of medication are most attached to it. It is not to be expected 
that in a disease so dangerous as the one under consideration any 
plan can be uniformly successful, even with advantages of accurate 
diagnosis and early treatment; but when it is remembered that 
the diagnosis between purulent metritis and puerperal peritonitis 
is not always easy, and that this medication is successful in pro- 
portion to its early adoption, we may probably find reason for its 
failure in other hands as well as in my own. 

"By way of illustrating the vigilance and discretion which must 
be exercised in the administration of each successive dose of the 
opiate in this mode of treatment, I will add that it could never 
have been fairly tested by me without the zealous, intelligent, 

38 



594 PUERPERAL METRO-PERITONITIS. 

and untiring assistance of the house-physicians of the Hospital. 
They visited the patients every hour by night as well as by day, 
and every dose of the medicine, from the first case to the last, was 
given by them, and proportioned to the hourly exigencies. Dr. 
Stephen Smith, of this city, now surgeon in the same Hospital, 
had the immediate charge of the first three successful cases. It 
was his judgment in carrying out the details that gave me confi- 
dence in the new treatment. Others, then of the house staff, to 
whom my acknowledgments are also due, are Dr. Brodie, of S. C. ; 
Dr. Frederick Nash, of this city; Dr. Charles H. Rawson, and 
Dr. Moneypenny." 

I think I shall also do a favor to my readers by quoting from 
Prof. Fordyce Barker the report of a case which he rendered to 
the New York Academy of Medicine in discussion of puerperal 
fever, October 7th, 1857. It is intended to show his mode of ad- 
ministering verat. viride. 

" Kate Short, aged 23 years, fell in labor in full term at 2 
o'clock P. M., February 25th, and was delivered of a healthy child 
at 8J o'clock on the morning of the 26th. Nothing unusual oc- 
curred in her labor, except that the second stage was somewhat 
prolonged. Placenta came away in due time, and was not followed 
by hemorrhage. First pregnancy. 

" February 28th, at 8 A. M., she was seized with a very severe 
chill, followed by increased frequency of pulse, and pain over 
hypogastric region, extending as high up as the umbilicus. This 
pain was very much increased by taking a full inspiration, or by 
the application of pressure. Tympanitis very considerable ; the 
discharge abundant and very offensive ; pulse 140 ; respiration 24. 

" At 1 o'clock P.M., Dr. Barker saw her, and recommended that 
she should be transferred to the Fever Wards, and put on the use 
of the tinctura veratri viridis. 

"At 2 o'clock p.m., after having been removed to the Fever 
Wards, her pulse was 140 ; respirations 24 ; pain over hypogas- 
tric region intense; tympanitis very considerable ; discharge abun- 
dant and very offensive; no mammary secretion. Dr. Barker re- 
quested that she should be seen hourly by one of the house staff, 
and that her condition, as to the state of the pulse, respiration, 



CURATIVE TREATMENT. 



595 



and other symptoms, and the dose of the veratrum viride given, 
should be recorded at each visit. The following is the record thus 
kept: 



Hour. Pulse. Repp. Drops. 



Feb'y 28th. 



March 1st. 



2 p.m. 140 

3 127 

5 140 

6 132 
120 



7 

8 

9 
10 
11 
12 

1 A.M. 

2 
3 
4 
5 



1 P.M. 





2 


92 


24 




3 


76 


24 




4 


76 


28 




5 


68 


28 




6 


66 


28 




7 


68 


26 




8 


66 


18 




9 


68 


24 




10 


60 


28 




11 


64 


28 




12 


66 


28 


March 2d. 


1 A.M. 


56 


32 




2 


70 


24 



3 


76 


24 


4 


4 


65 


20 


3 


5 


78 


22 


8 


6 


68 


22 


4 


8 


64 


24 


4 


9 


72 


24 


6 


10 


64 


28 


2 



Bowels moved once. 

Vomited a greenish-colored fluid. Bowels loose. 

Vomiting ceased. Bowels moved once. 



Respiration very irregular. Inclined to sleep. 

Sleeping. 

Hiccough and headache. 

Hiccough still continues. 

Severe headache. Vomited a greenish-colored fluid 

Headache severe, and very restless. Vomited several 

times within last hour. Hiccough. 
Vomited once since last visit. Vertigo and headache. 
Sleeping. 

Slight hiccough. 

Tenderness over abdomen, marked. Tympanitis 
somewhat diminished. Discharge dark, bloody, 
and very offensive. 

Visit of Prof. Barker. 

Face flushed. 

Sleeping. 

Sleeping. 

Slight hiccough. Bowels moved once. 
Vomited a greenish-colored fluid. 
Vomited once since last visit. 
Sleeping. 
Still sleeping. 
Sleeping still. 

Complains of pain in left thigh. There is slight 
swelling, and along its internal surface, over the 
course of the veins and lymphatics, the tenderness 
is so great that she can scarcely bear the lightest 
touch. Tenderness over abdomen still continues. 
Slight tympanitis. Discharge abundant, dark, 
bloody, and very offensive. No mammary secre- 
tion. 

Sleeping. 



Bowels moved once. 



596 



PUERPERAL METRO-PERITONITIS. 



Hour. Pulse. Resp. Drops. 
March 2d. 11 a. m. 72 28 6 

12 70 24 5 

1 P. M. 64 24 3 





3 


64 


24 








6 


68 


28 


3 






7 


72 


28 


5 






9 


80 


28 


6 


Face flushed. 




10 


80 


26 


6 






11 


80 


28 


8 






12 


80 


28 


10 


Sleeping. 


March 3d. 


1 A.M. 


80 


29 




Vaginal disci 



2 


78 


28 


10 


3 


80 


28 


8 


4 


72 


20 


4 


5 


68 


28 




6 


64 


24 




8 


60 


24 




10 


68 


24 


5 


11 


70 


24 


3 


12 


76 


28 


6 


1 P.M. 


80 


28 


6 


2 


80 


22 


8 


3 


76 


30 


4 


4 


76 


26 


5 


5 


72 


32 


4 


7 


64 


32 


2 


8 


72 


28 


5 


9 


68 


30 


4 


10 


68 


28 


3 


11 


72 


28 


5 


12 


70 


30 


7 


4th. lA.M. 


72 


32 


8 



2 


70 


30 




3 


64 


28 


2 


4 


64 


28 


3 


5 


60 


24 


2 


6 


60 


28 


2 


7 


60 


28 


2 


8 


58 


28 




9 


60 


28 




10 


56 


28 


2 


11 


64 


32 


3 


12 


72 


24 


4 


1 P.M. 


78 


32 


6 


2 


80 


28 


8 


3 


80 


24 


8 


4 


80 


30 


8 


5 


80 


28 


8 


6 


60 


32 





now ceases to be offensive. No 
mammary secretion. Tympanitis still remains. 
Tenderness over abdomen still continues, though 
not so well marked. Tenderness and swelling in 
left thigh still continues. 



Slight hiccough. 



Vomited a greenish-colored fluid, 
cough. Bowels moved twice. 



Headache. Hic- 



Sleeping. 



Sleeping. 

Tenderness over abdomen not so intense. Slight 
tympanitis. Vaginal discharge now appears to be 
natural. Tenderness and swelling on internal 
surface of left thigh now seems to be diminishing. 
No mammary secretion. 



Bowels moved twice. 



Sleeping. 



CURATIVE TREATMENT. 



597 



Hour. Pulse. Resp. Drops. 



March 4th. 


7 P 


M. 


64 


24 


6 




8 




60 


24 


2 




9 




60 


28 


2 




10 




60 


24 


2 




11 




60 


26 






12 




58 


24 




March 5th. 


1 A. 


M. 


60 


22 


3 



2 


68 


26 


4 


3 


60 


22 


2 


4 








5 








6 


70 


30 


6 


7 


64 


24 


4 


8 


76 


24 


6 


9 


76 


24 


6 


10 


72 


28 


6 


11 


64 


24 


3 


12 


68 


24 


6 


1 P.M. 


64 


28 


5 


2 








3 


56 


28 




4 








5 


64 


24 


5 



She now says she feels much better. Her counte- 
nance looks much brighter, and she appears to be 
much improved in every respect. The tenderness 
which has been so intense over the abdomen, now 
is scarcely noticeable. Tympanitis very slight. 
Discharge very scanty, but normal. No mam- 
mary secretion. The swelling and tenderness on 
the internal surface of the thigh, in the course 
of the veins and lymphatics, has now disappeared 
altogether. 

Sleeping. 



26 



10 72 

March 6th. 8 A.M. 70 



76 



March 8th. 10 a.m. 76 



•24 





1 P.M. 


72 


24 




5 


78 


28 




6 








7 


76 


26 




8 








9 








10 


72 


24 


March 7 th. 


9 A.M. 


76 


24 



24 



Feels well; improvement marked. No tenderness 
on pressure over abdomen. No tympanitis. Dis- 
charge still scanty, but normal. Slight mammary 
secretion. 



She says she feels well and hearty. No tenderness 
over abdomen. No tympanitis. Vaginal discharge 
healthy. No tenderness or swelling in left femoral 
region. Appetite good. Bowels regular. 

Continues to improve Very fast. 



" From this time she continued to improve, and in a short time 
was discharged as well and hearty as she ever was. 



598 PUERPERAL METRO-PERITONITIS. 

" Now here is a case occurring in a hospital, at the time of an 
epidemic, presenting a combination of symptoms which all familiar 
with the disease would pronounce truly alarming. By the verat. 
virid. the pulse was brought down from 140 to 60 per minute, and 
it was never permitted to rise above 80. The quantity adminis- 
tered varied according to the condition of the patient, two, three, 
or four drops being frequently sufficient to control the vascular 
excitement. No other medicine was used. In many other puer- 
peral cases, I have seen equally striking results. I will briefly 
mention one which I saw, in consultation with Dr. Sayre, the tenth 
day after confinement. She was a primipara, and her convales- 
cence seemed perfectly normal, until the sixth day, when she began 
exhibit some appearance of mental disturbance. She was espe- 
cially anxious in regard to her religious condition. Gradually a 
high state of nervous excitement was developed, with insomnia, 
and when seen by myself, she had been decidedly maniacal for 
more than twenty-four hours. Her respiration was short and 
hurried, her pulse very rapid, her countenance anxious and fright- 
ened ; she was incessantly talking and starting with apprehension, 
from the slightest movement in the room. No physical explora- 
tion could be obtained, but there were no local symptoms indicat- 
ing pelvic trouble. She sat up in bed, and moved from one part 
to another with great rapidity. The verat. virid. was now given, 
and by its influence the pulse was brought down below 70 per 
minute, the respiration became slower, the mind tranquil, and she 
was enabled to sleep. I am informed by Dr. Sayre that in the 
course of a few days there was developed, in the pelvic cavity, an 
extensive abscess, which pointed externally, near the sacrum. 
Her convalescence was somewhat prolonged, but she eventually 
recovered." 

I quote from these two eminent teachers with the hope to enable 
them to impart to my readers not only the information but the 
spirit so apparent in them. The great quantities of these medi- 
cines administered, and the profound effects produced by them, 
may be considered by some as recklessness, and, in many acute 
diseases, such imputation would be just, but in puerperal perito- 
nitis anything short of this would be culpable dereliction. 



CHAPTER XXXIII. 

STOMATITIS MATEKNA— JMUESI^TG SOKE MOUTH. 

This, as its name implies, is a disease peculiar to those who are, 
or who are about to be, mothers, and is attended with painful in- 
flammation of some portion of the lining membrane of the mouth. 

Although inflammation of the mouth is a symptom considered 
necessary to the full development of the disease, it must be re- 
garded only as a symptom attending a general condition of the 
whole system, or, at least, of some one of its elementary constit- 
uents, perhaps the blood, which, by its own peculiar modification, 
implicates the solid parts in an action which they would not other- 
wise take upon themselves. 

This view of its pathological seat, it is believed, is the only one 
which will enable us satisfactorily to account for many of the phe- 
nomena presented, both in respect to the time of occurrence, and 
the particular solid tissue affected. 

What this modification of the condition of the blood may be, we 
can only conjecture ; as, in the present state of science, the inves- 
tigations, which have extended only to the physical and chemical 
qualities of this fluid, do not afford the means of ascertaining with 
any exactitude many of the most important changes which occur 
in it. 

What are its vital conditions under varied circumstances, or in- 
deed, in any case, perhaps, is entirely beyond the reach of our 
philosophy ; and, it may be, will ever elude the imperfect means 
of research attained by the ingenuity of man. 

If the pathological condition of the system is that of anaemia re- 
sulting from pregnancy and lactation, there must be some peculi- 
arity about it, judging from its effects, differing from anaemia arising 
from other causes. 

Several cases have occurred in my practice in women who were 
pregnant with their first child, which continued throughout the 
remaining time of gestation and during lactation. I remarked 



600 STOMATITIS MATERNA. 

that all the patients in whom these cases occurred were very young, 
of scrofulous diathesis, weakly, and labored under most of the 
symptoms of ansemia resulting from other exhausting influences, 
such as pallor, languor, shrunken veins, &c. 

I think that without other influences, pregnancy and lactation 
are not sufficient, and hence I believe we must look for extrinsic 
causes ; and these are, probably, endemic and epidemic. By the 
former, I mean such morbific agents as are operating in the imme- 
diate locality of the patient; for, so far as I can learn, it is not 
of very general prevalence. 

By the epidemic influence, I mean the extensive change which 
has taken place in the general cast of the diseases of the West, 
especially along the course of the large rivers, from the ordinary 
endemic bilious fever, and other miasmatic diseases, to the ty- 
phoidal, or continuous type, attended for the most part with affec- 
tions of the mucous membranes, particularly of the alimentary 
canal. 

There are three different varieties of this disease. The first 
includes the most simple variety, so far as local symptoms are 
concerned. It is characterized by a superficial and often diffused 
inflammation of the mucous membrane of the mouth, which may 
be confined to a small part, as the lips, or the end of the tongue ; 
or it may spread throughout the whole cavity of the mouth and 
fauces. 

The parts, upon examination, are found of a scarlet-red color, 
and dry ; but as a general thing not much, if at all, swollen. This 
appearance may be of transient duration, lasting, probably, only 
for a few hours, more generally, however, for several days, when 
in a great many instances it completely subsides, leaving the pa- 
tient to all appearance quite well, with the exception of a little 
debility. 

In some cases the subsidence is not so complete, and amounts to 
only a very considerable remission of the soreness and distress.* 

After an uncertain length of time — in slight cases longer, and 
shorter in severe ones — the inflammation returns, and runs a simi- 
lar course to the former paroxysm. 

The paroxysms usually commence suddenly, with a sense of 
burning or scalding in some part of the mouth, — oftener, perhaps, 
on the end of the tongue than elsewhere, — which rapidly spreads, 



SYMPTOMS. 601 

involving the parts continuously, until the whole mouth feels as 
if it had been scalded, and the acts of mastication and degluti- 
tion are intolerably painful. The subsidence of the pain and suf- 
fering is as sudden and gratifying as its onset was unexpectedly 
afflicting. 

The second variety seems to engraft itself, as it were, upon the 
diffuse and superficial inflammation of the first. In addition to 
the above appearances described, a crop of vesicles are scattered 
over the whole or a part of the inflamed surface. These are often 
so clear and transparent, that without attention they may be over- 
looked ; sometimes, again, they have an aphthous appearance, and 
are quite obvious. The duration of this eruption is about eight 
or ten days ; but it often lasts much longer, and then consists of 
successive crops. 

Although the symptoms subside sometimes as completely as in 
the former variety, the respite from suffering is commonly shorter 
and less complete. 

In the progress of a case, it is not unusual for the appearances 
described as the two varieties to alternate with each other. 

In the third variety, the whole force of the paroxysm is con- 
centrated upon a small part of the surface, always, in my expe- 
rience, upon the tongue, either upon its side or inferior surface. 
I have seen it begin with a fissure gradually leading to an ulcer, 
from a hardened tubercle, from the bursting of a vesicle, or simply 
from an inflamed point. However it may commence, a rapid ul- 
ceration destroys the substance of the tongue, until a ragged 
notched line half completes its amputation. Suddenly it ceases, 
the cavity granulates, fills up, and heals, but the organ is left dis- 
torted. The patient flatters herself, upon the cessation of each 
paroxysm, that some newly applied remedy is an all-sufficient 
sanative against the ills which she knows by experience are in re- 
serve for her. But, unfortunately, with a returning paroxysm, 
she finds her suffering unmitigated. Notwithstanding this fearful 
ulcerative process, this variety is less dangerous and affects the 
constitution more mildly than either of the other varieties. 

A very important consideration in connection with the local 
manifestation of the disease is, that the first two varieties are mi- 
gratory, travelling from the mouth along the surface of the mu- 
cous membrane to all the neighboring cavities, down through the 



602 STOMATITIS MATERNA. 

pharynx and oesophagus to the stomach ; and thence through the 
whole extent of the alimentary canal, frequently finding perma- 
nent lodgement in some section of the extensive tube, and destroy- 
ing the patient by originating chronic gastritis, duodenitis, ileitis, 
&c, or passing through the larynx, trachea, and into the bronchia. 
And if it does not, by establishing inflammation in some portion 
of these tubes, exhaust the patient (by originating chronic gastri- 
tis or duodenitis), it may awaken into existence the more fearful 
affections of the substance of the lungs. It has also followed the 
nasal passages into the different cavities of the skull, or maxil- 
lary antrum, and there induced permanent inflammation. At 
other times it travels through the Eustachian tube to the tympa- 
num, and thence to the mastoid cells. And I have seen one case 
where permanent deafness of one ear and exfoliation of bone from 
the mastoid process occurred. The most common course for it to 
take, is into the alimentary canal and lungs. It is very prone to 
fasten fatal disease upon the lungs, when it is allowed to run on 
for any considerable length of time. 

The date of the commencement of the above local symptoms is 
various. Hitherto, I believe it has been considered that they date 
from some time during the term of lactation, especially where the 
subject is young, and with the first child, but that they might re- 
appear during subsequent pregnancies ; and that they never are 
present in pregnancies, unless the patient has been subject to the 
disease during some previous term of lactation. 

I am not certain that this is the general rule ; but it is unques- 
tionably the fact, that the woman will be more likely to experience 
such trouble after having once labored under the malady. 

Accompanying the above array of symptoms are those of a gen- 
eral character. Perhaps, of all others, disorder of the digestive 
organs is the most prominent, as well as first in importance. 
Difficulty of deglutition, indigestion, and diarrhoea, form a part 
of these. All of these symptoms, like the local, are more or less 
paroxysmal, — the diarrhoea particularly. For some time it will 
harass the patient, exhaust the resources of her system, and then 
disappear, and allow her to recruit strength, to be prostrated 
again by its return. Indigestion is, probably, more or less con- 
stantly present. 

Difficulty of mastication and deglutition vary, of course, with 






TREATMENT. 603 

the local symptoms. Emaciation is also often considerable, and 
generally keeps pace with the digestive disorders. 

Many other general symptoms might be enumerated, but as they 
are not peculiar or so important, they will not be noticed. 

Treatment. — The first step in the cure of any disease, should 
be the removal of the cause when practicable. In cases where 
more than one cause contributes to the production of disease, the 
removal of one of them may so far interrupt the chain of impres- 
sions as to accomplish a cure. 

Occasionally, this is found to be the case in the disease under 
consideration. The patient, by a change of her residence for the 
balance of the time of lactation, may get quite well. This, how- 
ever, is not generally the case ; and in all instances where the ob- 
jections are not too weighty, the child should be weaned, or trans- 
ferred to another nurse. I have seen so many cases of unfortunate 
terminations, and regard the condition of my patients so uncertain 
while laboring under this ubiquitous inflammation, in which, with- 
out any warning, some vital organ is involved, and it becomes the 
seat of destructive organic alteration, that I deem it a matter of 
great importance to take immediately the most effectual course 
within my knowledge to place the patient under the most favora- 
ble circumstances. 

After an experience of many years' duration, I cannot feel quiet 
while my patient, if at all seriously affected, continues to nurse 
her child. I am thoroughly convinced that, in many instances 
which I have known to be followed by fatal secondary diseases, 
had the connection between the sore mouth and them been properly 
appreciated, and the causes of it understood, the mother's life 
would not have been sacrificed in a useless attempt at nursing ; 
and I am well assured that, with the best management in grave 
cases, there is much more likelihood of the patient becoming worse 
than better while she nurses her child. I will also say that, in 
some cases, weaning will not of itself cure, although this is the 
general rule. 

The most obvious and urgent indication for treatment will be 
found in the emaciation and debility. We must meet them with 
tonics and proper diet. Animal food, in as liberal quantities as 
the enfeebled digestive apparatus will allow, must be given. Milk, 
eggs, and mutton, I have found to agree best. 



604 STOMATITIS MATERNA. 

First upon the list of medicines may be placed cod-liver oil. It 
must be persevered in during the whole term of lactation, and as 
long after as any traces of the disease exist. The dose should be 
regulated by the capacity of the stomach, as much being given as 
can be retained. This remedy has the advantage of any other al- 
terative and tonic in its soothing effects upon the irritated bowels 
when this difficulty exists. 

This is a circumstance of the utmost importance, as we are often 
interrupted in the use of remedies by diarrhoea. 

When there is no diarrhoea, or between the paroxysms of it, the 
most useful tonic, next to the oil, is the carb. of iron, prepared 
and used according to the following formula : 

R. Carb. potass., 

Sulph. ferri, aa, . . . . . . ^jss. 

Gum acacia mucil., ^iv. 

Pulverize the potass, and dissolve in the mucilage ; then pul- 
verize, and add the sulph. of iron ; mix well in an earthen mortar. 
Dose : half an ounce three times a day, gradually increasing to 
as much as the stomach will bear. 

For persons very much reduced, of lax habit, brandy or wine, 
taken during meals, will sometimes do good. Very often they both 
disagree, when we may substitute ale, porter, or beer. Vegetable 
tonics and aromatics are useful in certain cases, where the iron 
disagrees with the stomach. 

The diarrhoea, so exhausting to the patient and perplexing to 
the physician, should claim our attention also. Indeed, while this 
symptom exists, our efforts to restore the wasted energies of the 
system, and remove the unnatural condition of the blood, from an 
inability to introduce effective tonics, will be futile. 

Entire quietude, while the diarrhoea is in active existence, in 
the horizontal position, should be strictly enjoined. Morphia, 
combined with acetate of lead, will often control it very completely. 
We may replace the latter remedy by sulphate of copper or nitrate 
of silver. This latter, when given with solid opium, often answers 
an excellent purpose in quieting the irritation of the bowels, and 
acting also as a tonic. Astringent injections and suppositories 
may also be used to advantage. Indeed, in some instances all our 
resources will be vainly tried to relieve this symptom. 



TREATMENT. 605 

A great variety of local remedies have been put in requisition, 
and all have enjoyed more or less reputation. I have used with 
benefit a solution of sulphate of copper, of different degrees of 
strength, the vinous tincture of Hydrastis Canadensis, a weak 
solution of nitric acid, sulphate of alum, borax, and sulphate of 
zinc ; some agreeing in one case, and some in another. The only 
way I have ever been able, with certainty, to adapt the local rem- 
edies to different cases, was by trying them. 



INDEX. 



Abdominal supporters, 166, 311. 
Abortion, 162, 168. 
Abscess, glandular, of the mammae, 483. 
of labia, 21. 
milk, 480. 

treatment of, 497. 
Absence of menses, 68. 

of secretion of milk, 508. 

treatment of, 509. 
of uterus, 71. 
Accident in injection, 251. 
Accidents and diseases of the labia and 

perineum, 17. 
Acid nitrate of mercury, 269. 

solution of nitrate of silver, 262. 
Acute cellulitis, 184. 
Acute inflammation after parturition, 
221. 
supervention of, 220. 
of mammary glands, 501. 
of mucous membrane of uterus, 130. 
of unimpregnated uterus, 126. 
causes of, 126. 
diagnosis of, 128. 
prognosis of, 127. 
symptoms of, 126. 
treatment of, 128. 
vaginitis, 46. 

causes of, 47. 
diagnosis of, 46. 
prognosis of, 46. 
treatment of, 47. 
Adhesion of hymen, 72. 
of labia in adults, 18. 
in children, 17 

causes and cure of, 17. 
Affection of liver, sympathetic, 133. 
of sciatic and anterior crural 

nerves, 138. 
of spinal cord, 137. 
After-treatment, &c, subsequent to 
operations for ovarian tumor, cases 
illustrative of, 464-474. 
Agalactia, 509. 
causes of, 509. 
treatment of, 509. 
Air-bag, use of in menorrhagia, 94. 
Alterative, blue mass an, 81. 
turpentine an, 81. 



Amenorrhoea, 68. 

diagnosis of, 72. 

pathological states of, 68. 

prognosis of, 76. 

symptoms of, 68. 

treatment of, 77. 

tuberculosis as a cause of, 71. 
Anaesthesia, 139. 

Anatomy and nature of crural phlebi- 
tis, 543. 

and nature of toxaemic puerperal 
fever, 559. 

morbid, of puerperal metro-perito- 
nitis, 571. 

of ovarian tumors, 401. 
Anaemia, 88, 95, 230. 
Anteversion of uterus, 190, 306. 
Aphthous inflammation, 200, 269. 
Appearance of multiparous uterus, 211. 

os and cervix in the virgin, 211. 

secretion of cervix uteri, 212. 

uterus in the aged, 211. 
Application of nitrate of silver in cer- 
vical cavity, 262. 
Applications, caustic, diagnostic effect 

of, 214. 
Arrest of involution of uterus, 308. 
Astringent injections, 248. 
Atrophy, acquired, of the uterus, 75. 

a result of inflammation, 215. 

congenital, of the uterus, 74. 

produced by use of nitrate of sil- 
ver, 265. 



Bandage, use of in constipation, 239. 
Barker on puerperal fever, 595-598. 
Baths, 244. 
hip, 245. 
shower, 246. 
sponge, 247. 
temperature of, 246. 
Becquerel's diagnostic summary be- 
tween cancer and chronic inflamma- 
tion of the cervix, 217. 
Belladonna in the treatment of milk 

abscess, 500. 
Bennett on dysmenorrhoea, 102. 

on the unimpregnated uterus, 173. 



608 



INDEX. 



Bodies, mammary, 145. 
Bougies, medicated, 275. 

pressure by, in endocervicitis, 274. 
Bowels, sympathetic disease of, 132. 
Bran, use of in phlegmasia albadolens, 

501. 
Breast, cancer of, 512. 

chronic inflammation of, 504. 
Brown on rupture of perineum, 23. 



Cancer of the breast, 512. 
causes of, 517. 
diagnosis of, 515. 
prognosis of, 516. 
symptoms of, 513. 
treatment of, 517. 
of the uterus, 354. 
causes of, 360. 
diagnosis of, 361. 
prognosis of, 362. 
symptoms of, 357. 
treatment of, 363 
Cases illustrative of after-treatment, 
&c, subsequent to operation for 
ovarian tumors, 464-474. 
of absence of uterus, 73. 
Causes of acute inflammation of unim- 
pregnated uterus, 126. 
acute vaginitis, 46. 
adhesion of labia, 17. 
agalactia, 509. 
amenorrhcea, 68. 
cancer of the breast, 517. 

of the uterus, 359. 
cellulitis, 186. 
chronic vaginitis, 47. 
delayed involution of the uterus, 

346. 
diseased deviations of involution 

of uterus, 346 
displacements of uterus, 306. 
hyperinvolution, 352. 
mammary inflammation, 485. 
menorrhagia, 86. 
metatithmenia, 121. 
metro-peritonitis, 567. 
ovarian tumors, 411. 
perimetritis, 291. 
pruritis pudendi, 36. 
puerperal inflammation of the ute- 
rus, 565. 
puerperal vaginitis, 51. 
purulent vulvitis, 32. 
stomatitis materna, 600. 
subinvolution, 350. 
toxaemic puerperal fever, 559. 
vesico-vaginal fistula, 57. 
Caustic-holder, flexible, 258. 
Caustic applications, diagnostic effect 
of, 214. 
potash, 281. 



Caustic potash, mode of applying, 282. 
Cazeaux on pregnancy, 167. 
Cellulitis, acute, 184. 

chronic, 185. 
Cephalalgia, 134. 

Cervix, hardness and enlargement of, 
280. 
amputation of, 385. 
uteri, local symptoms of inflam- 
mation and ulceration of, 151- 
165. 
Character of mucus in vagina, 154. 
Characteristic signs of inflammation, 

213. 
Children, vaginitis in, 170. 
Chronic inflammation of the breast, 
504. 
diagnosis of, 505. 
prognosis of, 506. 
symptoms of, 504. 
treatment of, 506. 
of the uterus and cervix, 131. 
sympathetic accompani- 
ments of, 132. 
vaginitis, 46. 

causes of, 47. 
diagnosis of, 46. 
prognosis of, 46. 
symptoms of, 47. 
treatment of, 49. 
Clark on puerperal fever, 586-594. 
Cold, 166. 

Color of mucous membrane of cervix, 
211. 
leucorrhoea, yellow, sign of ulcera- 
tion, 155. 
Colpeurynter, 387. 

Complication of mucous with submu- 
cous inflammation, 200, 215. 
uterine disease with phthisis, 179. 
Complications of inflammation of cer- 
vix, 182-191. 
toxsernic puerperal fever, 559. 
Condition of uterus in abortion, 163. 
Congenital atrophy of the uterus, 74. 
Congestions, local, 231. 
Congestive dysmenorrhcea, 101. 
Constipation, 232, 88, 166. 

kneading to overcome, 238. 
use of bandage in, 239. 
Contraction of os uteri from use of ni- 
trate of silver, 265. 
Corroding ulcer of the labia, 33. 
Counter-irritant, seton as a, 280. 
Convulsions, syncopal, 140. 
Cramping pain, 158. 
Crural phlebitis, 543. 
Cures, spontaneous, 219. 
Cystitis as a complication of chronic 
inflammation and ulceration of cer- 
vix uteri, 216. 



INDEX. 



609 



Delayed involution of the uterus, 345. 
causes of, 345. 
prognosis of, 347. 
symptoms of, 346. 
treatment of, 347. 
Denman on ovarian dropsy, 442. 
Depression or lapse of uterus, 305. 
Derangement, moral and mental, 145. 
Dewees's pessary, 318. 
Diagnosis, 202-217. 

of acute inflammation of unim- 
pregnated uterus, 128. 
acute vaginitis, 46. 
amenorrhea, 68. 
cancer of the breast, 515. 
cancer of the uterus, 361. 
cellulitis, 185. 
chronic inflammation of the 

breast, 505. 
chronic vaginitis, 47. 
dysmenorrhea, 105. 
endocervicitis, 213. 
hyperinvolution, 352. 
inversion of the uterus, 333. 
menorrhagia, 89. 
metatithmenia, 119. 
ovarian tumors, 416. 
perimetritis, 295. 
phlegmasia alba dolens, 549. 
puerperal metro-peritonitis, 576. 
inflammation of the uterus, 
564. 
rectitis, 187. 
stone in the bladder, 42. 
submucous inflammation, 214. 
toxsemie puerperal fever, 558. 
tumors of the uterus, 378. 
Diagnostic effect of caustic applica- 
tions, 214. 
summary (Becquerel's) between 
cancer and chronic inflamma- 
tion of the cervix, 217. 
Diet, 225. 

Digital examination, 204. 
Disease of the bowels, sympathetic, 132. 
stomach, 131. 
of the skin an accompaniment of 

inflammation of uterus, 180. 
of the throat a complication of 

uterine affections, 180. 
uterine, etiology of, 166-171. 
Diseased deviations of involution of 
the uterus, 345. 
causes of, 345. 
prognosis of, 347. 
symptoms of, 346. 
treatment of, 347. 
Diseases and accidents of the labia and 
perineum, 17. 
of the mamma?, 475. 
of the vulva, 32. 
Disk pessary, 314. 



Disorders of menstruation, 68. 
Displacements, their philosophv and 
treatment, 302-344. 

causes of, 307. 

kind of, to which pessaries are 
adapted, 316. 

nature of, 304. 

symptoms of, 309. 

treatment of, 310. 

of the uterus. 189. 
theory of, 191. 
Dropsy, ovarian, 401. 
Duck-bill speculum, 393. 
D3-smenorrhoea, 99. 

diagnosis of, 105. 

nature of, 100. 

prognosis of, 105. 

treatment of, 105. 



Effect of suppuration of a milk-reser- 
voir, 503. 
of use of nitrate of silver in dys- 
menorrhcea, 267. 
upon menstruation, 266. 
upon os uteri, 265. 
Effects of partial closure of os uteri on 
menstruation, 158. 
of solid nitrate of silver, 263. 
of inflammatory excitement, 153. 
Ellis's treatment of ulceration, 275. 
Endocervicitis, 195. 
diagnosis of, 213. 
in aged women, 196. 
in virgins, 196. 
pressure by bougies in, 274. 
Endometritis, 108. 
Epitheliomatous growths, 385. 
Etioloo-v of phlegmasia alba dolens, 
543. 
of uterine disease, 166-171. 
Examination, digital, 204. 

physical, management of, 202. 
position of patient during, 203. 
Excitability, nervous, 228. 
Excrescences, urethral, 39. 
Excretory organs, sympathy of, 144. 
External inflammation combined with 
internal in childbearing women, 196. 



Fever, puerperal, 554. 
Fistula in ano, 187. 
recto-vaginal, 64. 

treatment of, 65. 
vesico-vaginal, 57. 
causes of, 57. 
preliminaries and instruments 

for operation for, 58-64. 
treatment and operation for, 
58, 59. 
Flexible caustic-holder, 258. 



39 



610 



INDEX. 



Flow, menstrua], modified by inflam- 
mation, 159. 
duration of, 159. 
Food, 228. 
Formation of tumors of the uterus, 

374. 
Forms in which nitrate of silver should 
be applied, 257. 
of ulceration, 198. 
Frequency of application of nitrate of 

silver, 260. 
Function of generation affected by in- 
flammation of uterus, 161. 



Galactorrhea, 510. 

prognosis of, 511. 

treatment of, 511. 
Gangrenous vulvitis, 35. 

nature of, 35. 

prognosis of, 36. 

treatment of, 36. 
General treatment, 219-243. 
Generation, function of affected by in- 
flammation of uterus, 161. 
Genital canal, occlusion of, 72. 
Glandular abscess of the mammas, 483. 

causes of, 485. 

symptoms of, 483. 

treatment of, 490. 
Globe pessary, 314. 
Gonorrhoea, 169. 

Governing principles of local treat- 
ment, 253. 



Hardness and enlargement of cervix, 
281. 

with atrophy, 193. 
Heart, palpitation of, 141. 
Hematocele, 115. 

Hemorrhage produced by use of nitrate 
of silver, 272. 

from wound of labia, 19. 

remedy for, when induced by use 
of nitrate of silver, 272. 
Hemorrhoids, 167, 188. 
Hip bath, 245. 
Hodge on constipation, 242. 
Hodge's pessary, 318. 
How to find the os uteri, 210. 
Hygroma, 385. 
Hymen, adhesion of, 72. 
Hyperesthesia, 138. 
Hyperinvolution, 351. 

causes of, 352. 

diagnosis of, 352. 

symptoms of, 352. 

treatment of, 352. 
Hypertrophy, 193. 

during pregnancy, 345. 

of the cervix, 285. 



Hypertrophy, diagnosis of, 285. 
treatment of, 285. 
of the rectal mucous membrane, 
189. 



Iliac region, pain in, 152. 

soreness in, 152. 
Ilium, pain in side above the, 152. 
Illustrations of various kinds of nipple, 

487-8. 
Improper reading, 166. 
Indication from pus produced by the 
vagina, &c, 212. 
of mucus in abundance, 212. 
Indigestion, 243. 
Indulgence, sexual, 166. 

Infiltration, sanguineous, 19. |f _ 

Inflammation, acute, after parturition, 

221. I 

supervention of, 220. 
of the unimpregnated uterus, 
126. 
and ulceration of cervix uteri, 

local symptoms of, 151-165. 
aphthous, 200. 
atrophy a result of, 215. 
characteristic signs of, 213. 
chronic, of uterus and cervix, 131. 
complication of mucous with sub- 
mucous, 201). 
external, combined with internal, 

in childbearing women, 196. 
intensity of, 197. 
mammary, causes of, 485. 
mucous, 194. 

seat of, 194. 
phlegmonous, of the breast, 476. 
position of, 192-196. 
progress of, 198. 
submucous, diagnosis of, 214. 
or fibro-cellular, 192. 
with ulceration and mucous 
inflammation, 277. 
of cervix, complications of, 182- 
191. 
complicated with cellulitis, 
184. 
cystitis, 216. 
rectitis, 187. 

urethral and cystic in- 
flammation, 183. 
vaginitis, 182. 
of the breast, chronic, 504. 

lymphatic glands of the mam- 
ma, 478. 
treatment of, 497. 
of the nipple, 477. 

treatment of, 490. 
uterus, 79. 

puerperal, 564. 
Inflammatory excitement, effects of, 153. 



INDEX. 



611 



Injections, 247. 

astringent, 248. 

manner of using — kind of syringe, 

247. 
medicated, 248. 
temperature of, 250. 
Instruments for using nitrate of silver, 
258. 
employed in operation for vesico- 
vaginal fistula, 58-64. 
Intercourse, sexual, during treatment, 

225. 
Intra-uterine pessary of Simpson, 82. 
Inversion of the uterus, 333. 
diagnosis of, 336. 
prognosis of, 336. 
symptoms of, 335. 
treatment of, 337. 
Involution of uterus, diseased devia- 
tions of, 345. 
Iodism, 448. 



Kind of displacements to which pessa- 
ries are adapted, 316. 
pain produced by application of 

nitrate of silver, 264. 
syringe to be used in injections, 
247. 
Kinds of nipple, illustrations of, 487. 
Kneading, use of in constipation, 238. 
Kiwisch on ovarian tumors, 453. 



Labia, abscesses of, 21. 

adhesion of in adults, 18. 
in childhood, 17. 

causes and cure of, 17. 
and perineum, diseases and acci- 
dents of, 17. 
rupture of during labor, 23. 
effects of, 24. 
treatment of, 25. 
corroding ulcer of, 33. 
oedema of, 20. 
wounds of, 18. 

hemorrhage from, 19. 
Labor, 168, 169. 
Lapse of uterus, 305. 
Laxative, compound confection of black 

pepper a, 81. 
Leeching, 278. 
Leucorrhoea, 153-155. 
Local congestions, 231'. 

symptoms of inflammation and 
ulceration of cervix uteri, 151- 
165. 
treatment, 244-255. 

governing principles of, 253. 
Loins, pain in, 151. 
Lumbar region, pain in the, 151. 



Lymphatic glands of the mamma, in- 
flammation of, 478. 
treatment of, 497. 



Mackintosh on dysmenorrhea, 101. 
Mamma?, diseases of, 475. 
glandular abscess of, 483. 
neuralgia of, 506. 
Mammary bodies, 145. 

glands, treatment of acute inflam- 
mation of, 50L 
inflammation, causes of, 485. 
Management of physical examination, 

203. 
Manner of using injections — kind of 

syringe, 247. 
Marley on the suppression of milk, 

500. 
Mastalgia, 506. 
Mastodynia, 506. 

Mechanical support in uterine dis- 
placements, 311. 
Medicated bougies, 275. 
injections. 248. 
washes, 245. 
Meigs on hemorrhage from the labia, 

19. 
Membranous dysmenorrhoea, 104. 
Menses, absence of, 69. 
retention of, 72. 
suppression of, 68. 
Menstrual flow modified by inflamma- 
tion, 159. 
Menstruation and its disorders, 67. 

physiological principles of, 67. 
effect of partial closure of os uteri 
on, 158. 
of use of nitrate of silver 
upon, 266. 
in dj^smenorrhoea, 267. 
misplaced, 115. 
pain during, 158. 
Menorrhagia, 86. 
causes of, 87. 
diagnosis of, 89. 
pathology of, 86. 
prognosis of, 90. 
symptoms of, 88. 
treatment of, 91. 
Metatithmenia, 115. 
causes of, 121. 
diagnosis of, 119. 
pathology of, 116. 
prognosis of, 121. 
symptoms of, 117. 
treatment of, 122. 
' Metritis, puerperal, 564. 
I Metro-peritonitis, puerperal, 567. 
I Milk abscess, 480. 

treatment of, 497. 
absence of secretion of, 509. 



612 



INDEX. 



Milk abscess, causes of, 509. 

treatment of, 509. 
Misplaced menstruation, 115. 
Mode of applying caustic potash, 282. 
attack of metro-peritonitis, 573. 
hardening nipples, 491. 
scarifying os uteri, 278. 
softening nipples, 491. 
using speculum, 210. 
Moral and intellectual perverseness. 
138. 
and mental derangement, 145. 
Morbid anatomy of puerperal metro- 
peritonitis, 571. 
of toxemic puerperal fever, 560. 
Mucous inflammation, 194. 

membrane of uterus, acute inflam- 
mation of, 130. 
Mucus in abundance, indication of, 
212. 
in vagina, character of, 154. 
Multilocular tumors, 447. 
Muscular weakness, 141. 



Nature and anatomy of crural phle- 
bitis, 543. 
and morbid anatom}- of toxaemic 

puerperal fever, 560. 
of cysts of ovarian tumors, 405. 
of displacements, 304. 
of dysmenorrhcea, 100. 
of gangrenous vulvitis, 35. 
of perimetritis, 288. 
of puerperal metro-peritonitis, 569. 
of tumors of the uterus, 367. 
Nervous excitability, 228. 

prostration, 226. 
Neuralgia of the mammae, 506. 
prognosis of, 507. 
symptoms of, 507. 
treatment of, 507. 
Neuralgic dysmenorrhcea, 103. 
Nipple, illustrations of various kinds 
of, 487, 488. 
inflammation of, 477. 
treatment of, 490. 
Nipples, mode of hardening, 491. 

of softening, 491. 
Nitrate of silver and its substitutes 
256, 276. 
application of in pregnancy, 273. 
effect of use of in dysmenorrhcea, 
267. 
upon menstruation, 266. 
upon os uteri, 265. 
instruments for using, 258. 
sometimes produces hemorrhage, 
pain, and nervousness, 272. 
Noma, 35. 
Nursing; sore mouth, 599. 



Occlusion of the genital canal, 72. 

of uterus, 75. 
(Edema of labia, 20. 
Operation for ovarian tumor, 458. 
for prolapse of uterus, 30. 
for restoration of perineum, 27. 
for vesico-vaginal fistula, 59. 
Opium, use of in puerperal peritonitis, 

586. 
Organs, excretory, sympathy of, 144. 
Os uteri, appearance of in the aged, 
211. 
in the multiparous, 211. 
in the virgin, 211. 
contraction of, from use of nitrate 

of silver, 265. 
how to find, 210. 
in the aged, 206. 
Oval pessary, 314. 
Ovaria, prolapse of, 309. 
Ovarian tumor, application of pres- 
sure to, 445. 
cases illustrative of after-treat- 
ment, &c, subsequent to opera- 
tion for, 464-474. 
operation for, 458. 
tapping for, 435. 
tumors, 401. 
causes of, 411 
diagnosis of, 416. 
nature of cysts, 405. 
pathology of, 402. 
prognosis of, 414. 
treatment of, 431. 



Pain, cramping, 158. 

during menstruation, 158. 

how produced, 156. 

in the iliac region, 152. 

in the loins, 151. 

in the sacral or lumbar region, 151. 

in the side above ilium, 152. 

produced by application of nitrate 
of silver, 264. 
Palpitation of the heart, 141. 
Pathology of amenorrhcea, 68. 

menorrhagia, 86. 

metatithmenia, 116. 

ovarian tumors, 401. 

stomatitis materna, 599. 
Patient, position of, in physical exami- 
nation, 203. 
Perimetritis, 288. 

causes of, 291. 

diagnosis of, 295. 

insidiousness of, case showing, 294. 

nature of, 289. 

prognosis of, 297. 

symptoms of, 292. 

treatment of, 298. 
Perineal pad, 26. 



INDEX. 



613 



Perineum, operation for restoration of, 

27. 
Peri-uterine hematoma, 115. 
Pessaries, 166, 313. 
Dewees's, 318. 
disk, 314. 
globe, 314. 
Hodge's, 318. 
oval, 314. 
ring, 314. 

Simpson's intra-uterine, 82. 
stem, 314. 
Phlebitis, crural, 543. 
Phlegmasia alba dolens, 543. 
diagnosis of, 549. 
etiology of, 545. 
nature and anatomy of, 543. 
prognosis of, 549. 
symptoms and progress of, 546. 
treatment of, 550. 
Phlegmon, 21. 
Phlegmonous inflammation of the 

breast, 476. 
Physiological principles of menstrua- 
tion, 68. 
Plethora, 96, 230. 
Porte-caustique, 258. 
Position of inflammation, 192-196. 

of patient in physical examination. 
203. 
Posture, exercise, and repose during 

treatment, 222. 
Potash, caustic, 281. 
Pregnancy, 167. 

hypertrophy during, 345. 

is nitrate of silver allowable in, 

273. 
should baths and injections be used 
in, 252. 
Pressure by bougies in endocervicitis, 
274. 
in ovarian tumors, 445. 
Probe, uterine, 208. 
Procidentia of the uterus, 320. 
diagnosis of, 323. 
extent of protrusion, 321. 
nature and causes of, 320. 
prognosis of, 323. 
treatment of, 323. 
Prognosis of acute inflammation of un- 
impregnated uterus, 127, 
acute vaginitis, 46. 
amenorrhea, 76. 
cancer of the breast, 516. 
cancer of the uterus, 362. 
chronic inflammation of the 

breast, 505. 
chronic vaginitis, 49. 
delayed involution of the uterus, 

347. 
diseased deviations of involution 
of the uterus, 346. 



Prognosis of dysmenorrhoea, 105. 
gangrenous vulvitis, 35. 
inversion of the uterus, 356. 
menorrhagia, 90. 
metatithmenia, 121. 
neuralgia of the mamma?, 507. 
ovarian tumors, 414. 
perimetritis, 297. 
phlegmasia alba dolens, 543. 
puerperal inflammation of the 

uterus, 565. 
puerperal metro-peritonitis, 577. 
toxsemic puerperal fever, 559. 
tumors of the uterus, 382. 
uterine diseases, 172-181. 
Progress and terminations, 197-201. 
of mucous inflammation, 198. 
phlegmasia alba dolens, 543. 
Prolapse of ovaria, 309. 
of rectum, 188. 
uterus, 305. 
Prostration, nervous, 226. 
Pruritis pudendi, 36. 
causes of, 36. 
treatment of, 37. 
Puerperal convulsions, 520. 
causes of, 520. 
diagnosis of, 531. 
prognosis of, 553. 
symptoms of, 525. 
treatment of, 534. 

during a paroxysm, 536. 
interparoxysmal, 536. 
obstetrical, 540. 
fever, 554. 

inflammation of the uterus, 564. 
causes of, 565. 
diagnosis of, 565. 
prognosis of, 565. 
treatment of, 565. 
metritis, 564. 
metro-peritonitis, 567. 
causes of, 567. 
diagnosis of, 576. 
morbid anatomy of, 571. 
nature of, 569. 
prognosis of, 577. 
symptoms of, 573. 
treatment of, 579. 
toxsemic fever, 557. 
causes of, 559. 
complications of, 559. 
diagnosis of, 558. 
nature and morbid anatomy 

of, 560. 
prognosis of, 559. 
treatment of, 561. 
varieties of, 555. 
vaginitis, 51. 

symptoms of, 52. 
treatment of, 53. 
Purulent vulvitis, 32. 



614 



INDEX. 



Purulent vulvitis, causes of, 32. 

treatment of, 33. 
Pus produced by the vagina or cervix, 
indication from, 212. 



Quadrivalve speculum, 209. 

mode of using, 210. 
Quassia in purulent vulvitis, 33. 
Quinia in gangrenous vulvitis, 33. 



Kectitis, 187. 
Recto-vaginal fistula, 64. 

treatment of, 65. 
Kectum, prolapse of, 188. 

stricture of, 187. 
Eegion, iliac, pain in, 152. 
lumbar, pain in, 151. 
pelvic, sympathetic pain in, 137. 
Remedy for hemorrhage induced by 
use of nitrate of silver, 272. 
nervousness induced by use of ni- 
trate of silver, 273. 
pain induced by use of nitrate of 
silver, 272. 
Removal of tumors from the uterus, 

311. 
Respiration, 142. 
Restoration of perineum, operation 

for, 27. 
Retention of the menses, 72. 
Retro-uterine hematoma, 115. 
Retroversion of the uterus, 306. 

and retroflexion of the uterus dur- 
ing pregnancy, 329. 
causes of, 329. 
diagnosis of, 331. 
prognosis of, 331. 
symptoms of, 330. 
termination of, 331. 
treatment of, 332. 
Ring pessary, 314. 

Rupture of labia and perineum during 
labor, 23. 
Brown on, 23. 
effects of, 24. 
treatment of, 25. 
of sphincter, 24. 



Sanguineous infiltration, 19. 
Scanzoni on diseases of females, 131. 
Scarification, mode of doing, 278. 
Seton as a counter-irritant, 278. 
Sexual indulgence, 166. 

intercourse during treatment, 225. 
Should baths and injections be used in 

pregnancy, 253. 
Shower bath, 246. 
Simpson on dysmenorrhea, 106. 



Simpson's uterine pessary, 82. 
Sims's operation for stone m the female, 
45. 
for vesico-vaginal fistula, 64. 
Skin disease with uterine inflammation, 

180. 
Sore mouth, nursing, 599. 
Spasms, 139. 

Speculum, duck-bill, 393. 
mode of using, 210. 
quadrivalve, 209. 
Sphincter, rupture of, 24. 
Sponge bath, 247. 
Spontaneous cures, 219. 
Stem pessary, 314. 
Sterility, 161. 

cured with cure of disease of ute- 
rus, 177. 
Stomatitis materna, 599. 
causes of, 600. 
pathology of, 599. 
symptoms of, 599. 
treatment of, 603. 
varieties of, 600. 
Stone in the bladder, 42. 
diagnosis of, 42. 
symptoms of, 42. 
rare occurrence of in the female, 

42. 
treatment of, 43. 
Subinvolution, 350. 
causes of, 350. 
treatment of, 352. 
Submucous inflammation, with ulcera- 
tion and mucous inflammation, 
277. 
or fibro-cellular inflammation, 192. 
Subsidence of the uterus, 190. 
Summary of Ellis's treatment, 275. 
Supervention of acute inflammation, 

220. 
Support, mechanical, in uterine dis- 
placements, 311. 
Supporters, abdominal, 166, 311. 
Suppression of the menses, 68. 
Sympathetic accompaniments of dis- 
ease of the uterus, 132. 
disease of the bowels, 132. 
liver, 133. 

nervous system, 134. 
pains in the pelvic region, 137. 
stomach, 131. 
Symptoms of absence of the menses, 69. 
acute inflammation of unimpreg- 

nated uterus, 126. 
acute vaginitis, 46. 
amenorrhoea, 69. 
cancer of the breast, 513. 
cancer of the uterus, 357. 
chronic inflammation of the breast, 

504. 
chronic vaginitis, 47. 



INDEX. 



615 



Symptoms of crural phlebitis, 546. 

delayed involution of the uterus, 
346. 

diseased deviations of involution 
of the uterus, 346. 

displacements of the uterus, 309. 

hyperinvolution, 351. 

inversion of the uterus, 334. 

local, of inflammation and ulcera- 
tion of cervix uteri, 151-165. 

menorrhagia, 88. 

metatithmenia, 117. 

neuralgia of the mamma?, 507. 

perimetritis, 292. 

puerperal metro-peritonitis, 573. 
vaginitis, 51. 

stomatitis materna, 599. 

stone in the bladder, 42. 

tumors of the uterus, 376. 
Syncopal convulsions, 140. . 
Syringe, kind of, 247. 



Tampon, use of in menorrhagia, 94. 
Tapping for ovarian tumors, 435. 
Temperature of baths, 246. 

of injections, 250. 
Theory of displacements, 191. 
Throat disease a complication of ute- 
rine affections, 180. 
Treatment of acute inflammation of 
mammary glands, 501. 
unimpregnated uterus, 128. 
acute vaginitis, 46. 
adhesion of labia, 17. 
agalactia, 509. 
amenorrhea, 77. 
cancer of the breast, 517. 

uterus, 363. 
chronic inflammation of the breast, 
506. 
vaginitis, 47. 
delayed involution of the uterus, 

347. 
diseased deviations of involution 

of the uterus, 347. 
displacements of the uterus, 310. 
dysmenorrhea, 105. 
galactorrhea, 510. 
gangrenous vulvitis, 35. 
general, 219-243. 

hardness and enlargement of cer- 
vix, 280. 
hyperinvolution, 352. 
inflammation of the lymphatic 
glands, 497. 
nipple, 490. 
inversion of the uterus, 337. 
local, 244-255. 
menorrhagia, 91. 
metatithmenia, 122. 
milk abscess, 497. 



Treatment of neuralgia of mamma?, 
507. 
ovarian tumors, 431. 
perimetritis, 298. 
phlegmasia alba dolens, 550. 
pruritis pudendi, 36. 
puerperal inflammation of the ute- 
rus, 565. 
puerperal metro-peritonitis, 579. 

vaginitis, 51. 
purulent vulvitis, 32. 
recto-vaginal fistula, 64. 
rupture of labia and perineum, 25. 
stomatitis materna, 603. 
stone in the bladder, 43. 
subinvolution, 351. 
submucous inflammation, 277-284. 
toxaemic puerperal fever, 561. 
tumors of the uterus, 385. 
ulceration, Ellis's, 275, 276. 
urethral excrescences, 40. 
vesico-vaginal fistula, 57. 
Tuberculosis a cause of amenorrhea, 

71. 
Tumors, multilocular, 446. 
of the uterus, 367. 
diagnosis of, 378. 
formation of, 374. 
nature of, 367. 
prognosis of, 382. 
symptoms of, 376. 
treatment of, 385. 
ovarian, 401. 

cases illustrative of after-treat- 
ment, &c, subsequent to op- 
eration for, 464-474. 
operation for, 458. 
removal of from the uterus, 311. 
unilocular, 444. 
Turpentine as an alterative, 81. 

Ulcer, corroding, of the labia, 33. 
Ulceration and enlargement of cervix, 
200. 
forms of, 198. 

■ Ellis's treatment of, 275, 276. 
Unilocular tumor, 444. 
Urethral excrescences, 39. 

treatment of, 40. 
Use of opium in puerperal peritonitis, 
586. 
of the tampon in menorrhagia, 94. 
of veratrum viride in puerperal 
fever, 595. 
Uterine disease, phthisis complicated 
with, 179. 
skin disease, 180. 
throat affection, 180. 
etiology of, 166-171. 
prognosis of, 172-181. 
displacements, mechanical support 
in, 311. 



616 



INDEX. 



Uterine probe, 208. 
Uterus, absence of, 73. 

acquired atrophy of, 75. 

acute inflammation of mucous 

membrane of, 130. 
amputation of, 344. 
and cervix, chronic inflammation 

of, 131. 
ante version of, 190, 306. 
cancer of, 354. 

condition of in abortion, 162. 
congenital atrophy of, 74. 
delayed involution of, 345. 
depression or lapse of, 305. 
diseased deviations of involution 

of, 345. 
displacements of, 189, 302. 
inflammation of, 79. 
inversion of, 333. 

diagnosis of, 336. 
prognosis of, 336. 
symptoms of, 335. 
treatment of, 337. 
involution of, arrest of, 308. 
occlusion of, 75. 
operation for prolapse of, 30. 
procidentia of the, 320. 
prolapse of, 305. 
puerperal inflammation of, 564. 
removal of tumors from, 311. 
retroversion of, 189, 306. 

and retroflexion of the, during 
pregnancy, 329. 
subsidence of, 190. 
sympathetic accompaniments of, 

132. 
tumors of, 367. 

unimpregnated acute inflamma- 
tion of, 126. 



Vagina, character of mucus in, 154. 
Vaginitis, 46, 169, 170, 182. 
acute, 46. 

causes of, 47. 

diagnosis of, 46. 

prognosis of, 46. 

symptoms of, 46. 

treatment of, 47. 
chronic, 47. 

causes of, 49. 

diagnosis of, 48. 

prognosis of, 49. 



Vaginitis, chronic symptoms of, 47. 
treatment of, 49. 
puerperal, 51. 
causes of, 51. 
symptoms of, 52. 
treatment of, 53. 
Varieties of puerperal fever, 554. 

of stomatitis materna, 600. 
Various kinds of nipple, illustrations 

of, 487, 488. 
Veratrum viride, use of in puerperal 

fever, 595. 
Vesico-vaginal fistula, 57. 
causes of, 57. 
operation for, 59. 
preliminaries and instruments, 59- 

64. 
treatment of, &c, 58. 
Virgin, appearance of the os and cer- 
vix in, 213. 
endocervitis in, 196. 
Vulva, diseases of, 32. 
Vulvitis, gangrenous, 34. 
nature of, 34. 
prognosis of, 36. 
treatment of, 36. 
purulent, 32. 

causes of, 32. 
treatment of, 33. 



Washes, medicated, 245. 

Weakness, muscular, 141. 

Weight, or bearing-down pain, 153. 

West on menorrhagia, 92 

White on inversion of the uterus, 338. 

Women, childbearing, external inflam- 
mation combined with internal in, 
196. 

Wounds of the labia, 18. 
hemorrhage from, 19. 



Yellow leucorrhoea, 155. 

always a sign of ulceration, 155. 
ulceration may exist when yellow 
leucorrhoea is absent, 155. 



Zinc chloride of, use of in purulent 
vulvitis, 33. 
sulphate of, as an injection in acute 
vaginitis, 47. 
in puerperal vaginitis, 54. 



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and numerous other Illustrations on Wood. A large royal octavo volume. 
Price, in cloth, . . . . • . . . . . $6.00 
" leather, 7.00 

"Written expressly for the use of students of medicine, and those of midwifery especially, its teachings are 
plain and explicit, presenting a condensed summary of the leading principles established by the masters of 
tbe obstetric art, and such clear, practical directions for the management of the pregnant, parturient, and 
puerperal states, as have been sanctioned by the most authoritative practitioners, and confirmed by the 
author's own experience. Collecting his materials from the writings of the entire body of antecedent writers, 
carefully testing their correctness and value by his own daily experience, and rejecting all such as were falsi- 
fied by the numerous cases brought under his own immediate observation, he has formed out of them a body 
of doctrine, and a system of practical rules, which he illustrates and enforces in the clearest and most simple 
manner possible." — Examiner. 

Canniff 's Manual of the Principles of Surgery. 

Based on Pathology, for Students, by Wm. Canniff, Licentiate of the 
Medical Board of Upper Canada; M.D. of the University of New 
York ; M.B. C.S. of England ; formerly House Surgeon to the Seamen's 
Hospital, New York; late Professor of General Pathology and the 
Principles and Practice of Surgery, University Victoria College, C. W. 
Octavo. $4.50 

"This manual is evidently the production of a man who is well informed on his subject, and who moreover 
has had experience as a teacher and as a practitioner. He has profited by the study of the best authors on 
the principles of surgery, tested practically their doctrines, and has presented his own views, well arranged 
and clearly expressed, for the advantage of others." — American Journal of Med. Science. 

Cleaveland's Pronouncing Medical Lexicon. 

TENTH EDITION. 

Containing the Correct Pronunciation and Definition of most of the Terms 
used by Speakers and Writers of Medicine and the Collateral Sciences. 
By C. H. Cleaveland, M.D., Member of the American Medical Associa- 
tion, etc., etc. A small Pocket Volume. . . . $1.25 

This little work is both brief and comprehensive ; it is not only a Lexicon of all the 
words in common use in Medicine, but it is also a Pronouncing Dictionary, a feature 
of great value to Medical Students. To the Dispenser it will prove an excellent aid, 
and also to the Pharmaceutical Student. This edition contains a List of the Abbrevia- 
tions used in Prescriptions, together with their meaning ; and also of Poisons and their 
Antidotes : two valuable additions. It has received strong commendation both from the 
Medical Press and from the profession. 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 11 

Carnochan's Contributions to Operative Sur- 
gery and Surgical Pathology. 

By J. M. Caenochan, Professor of Surgery in the New York Medical 
College, &c, &c. The Illustrations are drawn from Nature, and 
printed on large Plate Paper, Colored and Tinted. To be completed 
in Ten Parts. Parts 1, 2, and 3 now ready. Price per Part, 75 cents. 

Each part is complete in itself, and sold separately. 

Coxe's Epitome of the Writings of Hippo- 
crates and Galen. 

Translated by John Redman Coxe, M.D., late Professor in the Univer- 
sity of Pennsylvania, &c, &c. Octavo. .... $3.00 

Craigie's General and Pathological Anatomy. 

Presenting a View of the Present State of Knowledge in these Branches of 
Science. By David Ceaigie, M.D., F.R.S. Second Edition. Oc- 
tavo $3.00 

Dixon's Guide to the Practical Study of Dis- 
eases of the Eye. 

The Third Edition, carefully Revised, with Test Types and Illustra- 
tions $2.50 

"All who have attended Mr. Dixon's cliniques will be prepared for the remarkable excellence of this work. 
The style is excellent. It is both copious and precise. The author knows his subject, writes unaffectedly, 
Bticks to his point, and avoids repetition. It is a work of sterling and permanent value, carrying all the 
weight that belongs to years of skilful experience, and deserving, even as a hand-book, to rank with the best 
practical monographs in our language." — London Lancet. 

De Boismont's Hallucinations. 

A Rational History of Apparitions, Visions, Dreams, Ecstasies, Magnetism, 
and Somnambulism. By M. Beieeee de Boismont. Translated from 
the French. Octavo $2.50 

The contents of this very curious philosophical and interesting volume offers attrac- 
tions to many classes of readers. The Theologian will admire the vein of reverence 
and morality which pervades it ; the Philosopher will find much food for study and 
contemplation ; the Practical Physician will avail himself of the knowledge and expe- 
rience detailed in a great variety of cases ; the Lawyer will be deeply impressed by 
the necessity of vigilance, and the close study of the case before he gives in his verdict 
of insanity ; whilst the lover of the marvellous will find ample food for the gratifica- 
tion of his taste in the number of strange and picturesque authenticated facts thus 
carefully collected. 



12 LINDSAY AND BLAKISTON 7 S PUBLICATIONS. 



Durkee on Gonorrhoea and Syphilis. 

A Treatise on Gonorrhoea and Syphilis. By Silas Durkee, M.D., Fel- 
low of the Massachusetts Medical Society, &c, &c. A New and Revised 
Edition, with Eight Colored Illustrations. Octavo. . . $5.00 

" Dr. Durkee's production is one of those, the perusal of which impresses the reader in favor of the author. 
The general tone, the thorough honesty everywhere evinced, the philanthropic spirit observable in many pas- 
sages, and the energetic advocacy of professional rectitude, speak highly of the moral excellence of the 
writer ; nor is the reader less attracted by the skill with which the book is arranged, the manner in which 
the facts are cited, the clever way in which the author's experience is, brought in, and the lucidity of the 
reasoning, the frequent and extremely fair allusions to the labors of others, and the care with which the the- 
rapeutics of venereal complaints are treated." — Lancet. 

Duchenne on Localized Electrization. 

IN PREPARATION. 

Localized Electrization, and its Application to Pathology and Therapeutics. 
Translated from the French by J. N. Kadcliffe, M.R.C.S., &c, &c. 
To be completed in Three Parts, octavo. With numerous Illustrations. 

The researches of Dr. Duchenne have justly earned for him the designation among 
Continental writers of "The Father of Electro-Therapeutics." His great work on 
Localized Electrization is the most complete treatise that has yet been written on the 
Medical Uses of Electricity, and the application of this agent to diagnosis. 

Fuller on Rheumatism ? Rheumatic Gout, and 
Sciatica. 

Their Pathology, Symptoms, and Treatment. By Henry William 
Fuller, M.D., Fellow of the Royal College of Physicians, London; 
Physician to St. George's Hospital, etc. From the last London Edition. 
Octavo. $3.00 

This work has passed through Three Editions in England, and one in this country. 
Its favorable reception has induced the author, in preparing the present Edition, to 
bestow more than ordinary care in its revision, endeavoring to make it as complete and 
useful as possible by adding many practical suggestions, and by carefully recording 
the result of his experience as to the action of Eemedies recently introduced. Through- 
out the work much additional matter has been inserted, founded upon personal obser- 
vation, and information obtained from other sources, of great practical value. 

Flint's Clinical Reports on Continued Fever. 

Based on Analysis of one hundred and sixty-four Cases, with Remarks on 
the Management of Continued Fever, the Identity of Typhus and Typhoid 
Fever, Relapsing Fever, Diagnoses, &c, &c. By Austin Flint, M.D., 
Professor of the Principles and Practice of Medicine in the Bellevue Hos- 
pital Medical College, &c, dec. Octavo. .... $2,00 



13 



Gross' American Medical Biography of the 
Nineteenth Century. 

Edited by Samuel D. Gross, M.D., Professor of Surgery in the Jefferson 
Medical College, Philadelphia, &c, &e. With a Portrait of Benjamin 
Eush, M.D. Octavo. . . . . . . . . . $3.50 

This is a book which strongly commends itself to the notice of the Profession. It 
contains biographies of more than thirty physicians who flourished at the beginnicg 
of the nineteenth century, all known to fame, and most of them pleasantly remembered 
by the present generation of physicians as accomplished teachers in medicai science. 
The plan pursued by Dr. Gross in getting up the work appears to be judicious. He 
enlisted among his contributors those who were most competent, by acquaintance and 
sometimes by relationship, to give a correct portrayal of character and statement of 
facts ; so that there are almost as many writers as biographies. There is therefore 
diversity of style in the book, and more comprehensive biographical sketches than we 
could expect from the pen of one man. The writers are among the most eminent 
physicians of this country, furnishing an array of names which would not compare 
unfavorably with those of whom they write. 

Gardner on Sterility. Its Causes and Cura- 
tive Treatment. 

With a Preliminary Statement of the Physiology of Generation, and 
numerous Colored and other Illustrations. By A. K. Gardner, M.D., 
Fellow of the N. Y. Academy of Medicine, &c, &c. Octavo. . $3.00 

This somewhat remarkable book has had quite a large sale ; but few copies of it now 
remain in print, the plates having been recently destroyed by fire. 

Garratt's (Alfred C.) Guide for Using Medical 
Batteries. 

Showing the most approved Apparatus, Methods, and Rules for the Medical 
Employment of Electricity in the Treatment of Nervous Diseases, &c, &c. 
With numerous Illustrations. One Volume, octavo. . . $2.00 

" The large work on the same subject, and by the same author, is pretty well known to the Profession, but 
it is bulky and cumbrous, and by no means so practically useful. The present comparatively brief volume 
contains every thing of importance in regard to the various apparatuses useful to the Medical Electrician 
and the various modes of application for therapeutic purposes." — Lancet and Observer. 

Hewitt on the Diseases of Women. 

SECOND EDITION, ENLARGED AND REWRITTEN. 

Their Diagnosis, Pathology, and Treatment, including the Diagnosis of 
Pregnancy. By Graily Hewitt, M.D., Professor of Midwifery and 
The Diseases of Women, University College, &c. From the Second 
London Edition. Enlarged and in great part rewritten. With numerous 
Illustrations. Octavo. (In preparation.) 



14 LINDSAY AND BLAKISTON's PUBLICATIONS. 

Headland on the Action of Medicines in the 
System. 

By F. W. Headland, M.D., Fellow of the Royal College of Physicians, 
&c, &c. Sixth American from the Fourth London Edition. Revised 
and enlarged, One Volume, octavo $3.00 

Dr. Headland's work has been out of print in this country nearly two years, await- 
ing the revisions of the author, which now appear in this edition. It gives the only 
scientific and satisfactory view of the action of medicine ; and this not in the way of 
idle speculation, but by demonstration and experiments, and inferences almost as in- 
disputable as demonstrations. It is truly a great scientific work in a small compass, 
and deserves to be the handbook of every lover of the Profession. It has received the 
most unqualified approbation of the Medical Press, both in this country and in Europe, 
and is pronounced by them to be the most original and practically useful work that has 
been published for many years. 

Hille's Pocket Anatomist. 

Being a Complete Description of the Anatomy of the Human Body ; for the 
Use of Students. By M. W. Hilles, formerly Lecturer on Anatomy and 
Physiology at the Westminster Hospital School of Medicine. 

Price, in cloth, $1.00 

" in Pocket-book form, 1.25 

" Mr. Hilles, who has for some time been favorably known to us by his excellent little work on Regional 
Anatomy issued in London in 1857, now offers for the^se of students the most complete book of the kind we 
have ever seen. It is not intended to take the place of the larger and more finished text-book, but the au- 
thor's aim has been to furnish a brief description of the different tissues and organs cf the human body. As 
Btated in the Preface, the work is based upon a treatise known to the Profession as Savage's Anatomist, and, 
from its enlarged and altered form, it should be considered rather a new work than as a new edition of a 
former treatise. It is vastly superior in every respect to the Anatomical Remembrancer, so much used in this 
country; and we can, therefore, safely recommend it to the attention of students." — North American Medico- 
Chirurgical Review. 

Hewson's Surgical Diagnosis. 

By Addinel Hewson, M.D., one of the Surgeons to the Pennsylvania 
Hospital, &c, (Sec. (In preparation.) 

Henle's Treatise on General Pathology. 

Translated from the German, by Henry C. Preston, M.D. Octavo. $2.00 

Prof. Henle's eminent character as a distinguished medical teacher, and as the best 
modern pathological author, is too well known among German Students to need more 
than the announcement of his name and his work to insure an enthusiastic and grate- 
ful reception in the medical literature of any country or language. 

Jameson's Treatise on Epidemic Cholera. 

By H. G. Jameson, M.D., &c. Octavo -. $2.00 



LINDSAY AND BLAKISTON's PUBLICATIONS. 15 



Mackenzie on the Laryngoscope. 

The Use of the Laryngoscope in Diseases of the Throat. With an Appen- 
dix on Rhinoscopy, and Illustrations. By Morell Mackenzie, M.D. ; 
Physician to the Dispensary for Diseases of the Throat, etc., etc. In One 
Volume. Octavo. . . $2.00 

** While laryngoscopy was in its infancy, and before it had begun to engage to any extent the attention of 
the Profession, it was studied with the greatest care and enthusiasm by the author of this treatise. A personal 
friend of Czermak's, who has done more than any other continental physician to introduce the laryngoscope 
into practice, he has profited by the opportunities which he thus possessed of becoming acquainted with the 
anatomy and morbid anatomy of the larynx. But he has done much more than this. As will be seen by a 
perusal of this treatise, he has modified the instruments at present in use for the examination of the larynx, 
and has invented others for therapeutical purposes. Those who are anxious to study the diseases of the 
larynx and the mode of using the laryngoscope, cannot do better than purchase the treatise before us, as it 
is by far the best which has been published, and is thoroughly to be relied upon." — Glasgow Medical Journal. 

Mackenzie on Diseases of the Throat. 

Part L, Diseases of the Pharynx ; Part II, Diseases of the (Esophagus; 
Part III, Diseases of the Larynx and Trochea. Being the Jacksonian 
Prize Essay for 1863. Beautifully Illustrated. (In preparation.) 

Morris on the Pathology and Therapeutics 
of Scarlet Fever. 

By Casper Morris, M.D., Fellow of the College of Physicians of Phila- 
delphia, &c, (Sec. A New Enlarged Edition. Octavo. . $1.50 

u He who has been longest engaged in the observation and treatment of this disease, will look with respect 
and gratitude to any one who can throw light upon its nature and furnish hints for its successful treatment; 
while the younger practitioner will seek for counsel with an avidity proportioned to the violence of the cases 
he is called to treat, and will welcome every, even the feeblest, effort to aid him in the management of a dis- 
ease than which none is more formidable in its character and uncertain in its results. The following pages are 
the result of more than thirty years' observation in various public institutions, as well as private practice ; 
and each year of enlarged experience confirms me in the truth of the principles here inculcated." — Preface 
to Second Edition. 

Meig's Practical Treatise on the Diseases of 
Children. 

Thoroughly Revised, and in great part rewritten. By J. Forsyth Meigs, 
M.D. Octavo. (In preparation.) 

Murphy's Review of Chemistry for Students. 

Adapted to the Courses as Taught in the Principal Medical Schools in the 
United States. By John G. Murphy, M.D. In One Volume. $1.25. 

" This is an exceedingly well-arranged and convenient Manual. It gives the most important facts and 
principles of Chemistry in a clear and very concise manner, so as to subserve most admirably the object for 
which it was designed." — North Western Medical and Surgical Journal. 



16 LINDSAY AND BLAKISTON'S PUBLICATIONS 



Maxson's Practice of Medicine. 

A New Text-Booh on the Practice of Medicine. By Edwin R. Maxson, 
M.D., formerly Lecturer on the Institutes and Practice of Medicine in the 
Geneva Medical College. In One Volume. Royal 8vo. . $4.00 

"Judging from his work, he must be a correct observer, of plain, strong common sense, having the pro- 
gress and perfection of the healing art, and the amelioration of suffering, earnestly at heart, free from pre- 
judice, and open to conviction. The fact of employing, and thereupon recommending valuable remedial 
agents, as yet, for various reasons, under the ban, and misunderstood by many physicians, ia an honor to 
him, and gives a certain additional value to his book." — American Medical Monthly. 

MendenhalFs Medical Student's Vade Mecum. 

A Compendium of Anatomy, Physiology, Chemistry, The Practice of Medi- 
cine, Surgery, Obstetrics, Diseases of the Skin, Materia Medica, Phar- 
macy, Poisons, &c., &c. By George Mendenhall, M.D., Professor of 
Obstetrics in the Medical College of Ohio, Member of the American 
Medical Association, &c, &c. The Eighth Edition, Revised and En- 
larged ; with 224 Illustrations $2.50 

* This volume puts the student in possession of a condensed medical library. Its accuracy is a strong 
recommendation, while the portability of a volume containing the whole circle of medical science is a matter 
that will have weight with those for whose service the book was originally designed. The work is offered, 
too, extremely cheap, and will be found a valuable assistant even to a well-informed practitioner of any 
branch of medicine." — Boston Medical and Surgical Journal. 

Paget's Lectures on Surgical Pathology, 

Delivered at the Boyal College of Surgeons of England, by James Paget, 
F.R.S., Surgeon to Bartholomew and Christ's Hospital, dec, &c. The 
Third American from the Second London Edition, Edited and Bevised 
by William Turner, M.B., Lond. Senior Demonstrator of Anatomy in 
the University of Edinburgh, &c, &c. In One Volume, Boyal Octavo ; 
with Numerous Illustrations. 

Price, in bevelled cloth, ...... $6.00 

" in leather, . • 7.00 

In bringing the new Edition of Mr. Paget's work before the Medical Profession of 
this country, the publishers feel that but little is required to be said by them in refer- 
ence to it. Wherever the English Language is read or spoken, the work is highly 
valued and has been favorably received. Two large editions have been sold in the 
United States within a short period, which speaks volumes in its favor ; both the Pro- 
fession and the Medical Press unite in pronouncing it one of the most original works 
that has for a long time appeared in the English Language. 

Powell's Pocket Formulary 

and Physician's Manual, embracing the Art of Combining and Prescribing 
Medicines. With many Valuable Recipes t Tables, &c Bound in 
Leather, with Tucks and Pocket . $1.00 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 17 



Pereira's Physician's Prescription Book. 

Containing Lists of Terms, Phrases, Contractions, and Abbreviations, used 
in Prescriptions, with Explanatory Notes, the Grammatical Constructions 
of Prescriptions, Rules for the Pronunciation of Pharmaceutical Terms, 
A Prosodiacal Vocabulary of the Names of Drugs, etc., and a series of 
Abbreviated Prescriptions illustrating the use of the preceding terms, etc. ; 
to which is added a Key, containing the Prescriptions in an unabbreviated 
Form, with a Literal Translation, intended for the use of Medical and 
Pharmaceutical Students.* By Jonathan Pereira, M.D., F.R.S., etc. 
From the Fourteenth London Edition. 

Price, in cloth, $1.25 

" in leather, with Tucks and Pocket, .... 1.50 

This little work lias passed through fourteen editions in London and several in this 
country. The present edition of which this is a reprint has been carefully revised 
and many additions made to it. Its great value is proven both by its large sale and 
the many favorable notices of it in the Medical Press. 



Phy 



sicianS Visiting List. Published annually. 



■a 

SIZES AND PRICE 



For 25 patients weekly, bound in cloth, $0.75 

25 " " " leather, with Tucks and pocket, . . 1.25 

60 " " " cloth, 1.00 

50 " " leather, with Tucks and pocket . . 1.50 

100 '• " " " " " . . 2.50 

inft tl , t -oi fJan'y to June. \ bound in leather, with 

1UU in z vols - \ July to Dec'r. / Tucks and pocket, 3.00 

INTERLEAVED EDITION. 

25 patients weekly, interleaved and bound in cloth, .... 1.00 

25 " " " " " Tucks, with pocket, . . 1.50 

50 " " " " " cloth, .... 1.50 

50 " " " " " Tucks, with pocket, . . 2.00 

Prince's Orthopedic Surgery. 

Orthopedics: A Systematic Work upon the Prevention and Cure of 
Deformities. By David Prince, M.D. With Numerous Illustrations. 
Octavo $3.00 

"This is a good book, upon an important practical subject; carefully written, abundantly illustrated, and 
well printed. It goes over the whole ground of deformities of all degrees — from cleft-palate and club-foot, to 
spinal curvatures and ununited fractures. It appears, moreover, to be an original book, so far as one chiefly 
of compilation can be so. Such a book was wanted, and it deserves success." — Med. & Surg. Reporter. 

Rejmolds on the Diagnosis of Diseases of the 
Brain and Spinal Cord. 

By J. Eussell Keynolds, M.D., F.R.C.P., &c. (In preparation.) 

2 



18 LINDSAY AND BLAKISTON'S PUBLICATIONS, 

Radcliffe's Lectures on Epilepsy, Pain, Pa- 
ralysis, 

And certain other Disorders of the Nervous System, by Charles Bland 
Radcliffe, M.D., Fellow of the Royal College of Physicians of London, 
Physician to the Westminster Hospital, etc., etc. With Illustrations. 
12mo. . . $2.25 

"The reputation which Dr. Kadcliffe possesses as a very able authority on nervous affections, will commend 
his work to every medical practitioner. Disorders of the nervous system are very imperfectly comprehended, 
much concerning them being involved in mystery; and while Dr. Radcliffe has taken advantage of the ample 
room to theorize, which his subject afforded, he has not failed to bring forward strong and formidable facts to 
prove the deductions he attempts to draw. We recommend it to the notice of our readers as a work that will 
throw much light upon the Physiology and Pathology of the Nervous System." — Canada Medical Journal. 

Robertson's Manual on Extracting Teeth, 

Founded on the Anatomy of the Parts involved in the Operation ; the Kinds 
and Proper Construction of the Instruments to be used ; the Accidents 
liable to occur from the Operation, and the Proper Remedies to retrieve 
such Accidents. By Abraham Robertson, D.D.S., M.D., Author of 
"Prize Essay on Extracting Teeth," &c. In One Volume, with Illustra- 
tions $1.50 

" The author is well known as a contributor to the literature of the Profession ; and, as a clear, terse, for- 
cible writer, he has devoted considerable care to the subject, and treated it with his usual ability. The work 
is valuable, nof only to the dental student and practitioner, but also to the medical student and surgeon; and 
especially so to the military surgeon, who, in times like the present, is called upon so frequently to perform 
the operation of extracting teeth." — Dental Cosmos. 

Richardson on Local Anaesthesia. 

IN PREPARATION. 

Remak's Electro-Therapeutics. 

IN PREPARATION. 

Lectures on the Treatment of Nervous Disorders by the Application of the Con- 
stant Galvanic Current. Delivered at the Hospital of La Charite, Paris. 
By Dr. Robert Remak, Professor Extraordinary of the Medical Faculty, 
TJniversity of Berlin. Translated, with large Additions, by Meredith 
Clymer, M.D., late Professor of the Institutes and Practice of Medicine 
in the University of New York. 

These Lectures, delivered in the summer of 1865, by the celebrated Berlin Pro- 
fessor, before Committees appointed by the Imperial Academy of Sciences, and the 
Academy of Medicine, of Paris, are translated from the author's manuscript as fur- 
nished by him to the Revue des Cours Scientifiques. They have attracted much attention 
in Europe, and are the result of ten years' study of Electro-Therapeutics in the treat- 
ment of nervous disorders by one of the most scientific physicians of Europe. They 
contain the substance of his elaborate treatise, and the many valuable contributiona 
he has made to the medical periodicals on the important subject of Electrization 
applied to Pathology and Therapeutics. 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 19 



Ryan's Philosophy of Marriage. 

In its Social, Moral, and Physical Relations, with an Account of the Dis- 
eases of the Genito- Urinary Organs. The Physiology of Generation in the 
Animal and Vegetable Kingdoms, &c, &c. By Michael Ryan, M.D., 
Member of the Royal College of Physicians and Surgeons in London, &c. 
12mo * $1.25 

"Dr. Ryan is above reproach or suspicion; and with a singular degree of candor and independence, explains, 
in a true and philosophical manner, every branch of the subject which he considers essential to be under- 
stood by all intelligent persons." — Boston Medical and Surgical Journal. 

Banking's Half-yearly Abstract of the Medi- 
cal Sciences. 

Being an Analytical and Critical Digest of the Principal British and Conti- 
nental Medical Works published in the preceding Six Months. Published 
in Half yearly Volumes {paper covers), each containing about three hun- 
dred large octavo pages. 

Price, per annum, if paid in advance, .... $2.50 

Single volumes, 1.50 

The first thirty-two volumes, bound in sixteen volumes, leather, 

can be furnished each at 2.00 

Odd volumes, in paper covers, from 1 to 34, each at . 1.00 

Reese's Analysis of Physiology. 

Being a Condensed View of the most important Facts and Doctrines, de- 
signed especially for the Use of Students. By John J. Reese, M.D., 
Professor of Medical Jurisprudence, including Toxicology, in the Uni- 
versity of Pennsylvania, &c.,&c. Second Edition, Enlarged. 12mo. $1.50. 

Reese's American Medical Formulary. 

Including numerous Standard Formula?, derived from American and Euro- 
pean Authorities, together with the Medical Properties and Uses of Medi- 
cines ; Poisons, their Antidotes, Tests, &c. 12mo. . . $1.50 

Reese's Syllabus of a Course of Lectures on 
Medical Chemistry, &c. 

12mo. ....'. ..... . $1.00 

Stille's Elements of General Pathology. 

EN" PREPARATION. 

A Practical Treatise on the Causes, Forms, Symptoms, and Remits of Dis- 
ease. By Alfred Steele, M.D., Professor of The Theory and Practice 
of Medicine in the University of Pennsylvania, &c. 



20 LINDSAY AND BLAKISTON'S PUBLICATIONS. 



Sansom on Chloroform. 

Its Action and Administration, by Arthur Ernest Sansom, M.B., 

Physician to King's College Hospital, etc., etc. 12mo. . . $2*25- 

"The work of Dr. Sansom may be characterized as most excellent. Written not alone from a theoretical 
point of view, but showing very considerable experimental study, and an intimate clinical acquaintance with 
the administration of these remedies, — passing concisely over the whole ground, giving the latest kiformatioa 
upon every point, — it is just the work for the student and practitioner. The author may rest assured that, 
although in his preface he objects to the ' hackneyed expression of endeavoring to supply a want,' this is just 
what he has done — supplied and well supplied a want, for no such book existed before in our language."— 
American Medical Journal. 



Scanzoni's Practical Treatise on the Diseases 
of the Sexual Organs of Women. 

Translated from the French of Drs. H. Doe and A. Socin, and annotated 
with the approval of the authors. By A. K. Gardner, A.M., M.D., 
Professor of Clinical Midwifery, &c, &c, in the New York Medical Col- 
lege. With Numerous Illustrations. Octavo. . . . $5.00 

In the etiology, pathology, and therapeutics of female diseases, with all the im- 
provements which have been realized during the last twenty years, this volume is ex- 
ceedingly rich ; while in its arrangement it is so methodical that it must constitute 
one of the best text-books for students, and one of the most reliable aids to the busy 
practitioner. 



Stokes on the Diseases of the Heart and the 
Aorta. 

By William Stokes, Regius Professor of Physic in the University of 
Dublin ; Author of the Treatment and Diagnosis of the Diseases of the 
Chest, &c, &c. Second American Edition. Octavo. . . $3.00 

"The physician who has felt at the bedside the difficulty of diagnosis and treatment will best appreciate 
this book. It is eminently practical in its character, and yet it is no mere register of facts, strung together 
In unmeaning sequence, or to accommodate some arbitrary system. In the true spirit of inductive philosophy, 
the author has taken a higher range ; with him facts are but the instruments which he uses in high philo- 
lophic generalizations." — Edinburgh Med. and Surg. Journal. 



Skoda on Auscultation and Percussion. 

By Joseph Skoda. Translated from the Fourth German Edition, by 

- W. O. Markham, M.D., Assistant Physician to St. Mary's Hospital. 

12mo. $1.50 

" Since the great work of ' Leennec ' we have had none to equal it. Every page contains practical remarks 
of the highest interest. It will take a high place in standard medical literature." — Dublin Med. Press. 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 21 

Tanner's Practice of Medicine. 

A REVISED AND GREATLY ENLARGED EDITION. 

The Practice of Medicine, by Thomas Hawkes Tanner, M.D., Fellow of 
the Royal College of Physicians, Author of A Practical Treatise on the 
Diseases of Infancy and Childhood, etc., etc. Fourth American from the 
Fifth London Edition. Koyal Octavo. 

Price, bound in cloth, $6.00 

" ' " in leather, 7.00 

Dr. Tanner's work on the Practice of Medicine is so well known in this country, and 
has had such an extensive and rapid sale, that it seems almost unnecessary to say any- 
thing in reference to it; the present edition, however, contains such substantial addi- 
tions and alterations as almost to constitute it a new work, and from being a com- 
paratively small volume it now forms a handsome octavo of nearly 1000 pages ; all 
that was useful and practical in the smaller volume has been retained and much new 
matter added, written in the same condensed and easy style. 

" The leading feature of this book is its essentially practical character. Dr. Tanner has produced a more 
complete System of Medicine than any with which we are acquainted. It is the result of long experience and 
hard practice, and it is therefore valuable as a guide, and trustworthy as an exemplar." — London Lancet. 

Tanner's Practical Treatise on the Diseases 
of Infancy and Childhood. 

Octavo. . ' $3.00 

This book differs from other works of the kind, in embracing a wider range of sub- 
jects than is usually contained in treatises on children's diseases; besides the ordinary 
complaints of those subjects, it includes many affections which, though common to 
adults and children, yet offer some modification in form, or in the indications for treat- 
ment, when occurring in the latter. Thus, we have an account of diseases of the eye, 
ear, and skin, of small-pox, scrofula, tuberculosis, syphilis, bronchocele, and cretinism, 
diseases of the kidneys and genital organs, and some of the accidents common to child- 
hood. The style of the work is condensed, and the book might with truth be called 
a manual, rather than a treatise, but there is nothing superficial about it ; — every- 
thing really important is given, while the discussion of disputed subjects, and, in 
fact, of everything which is not of practical importance in the study and treatment of 
children's diseases, is omitted. 

Tanner's Index of Diseases and their Treat- 
ment. 

With upwards of 500 Formula for Medicines, Baths, Mineral Waters, 
Climates for Invalids, &c, &e. Octavo. .... $3.00 

" Dr. Tanner has been peculiarly happy in appreciating and supplying the wants of the Profession. Hi9 
Index of Diseases gives the derivation of words after the manner of a good Medical Dictionary ; an outline of 
every disease, including many surgical diseases, with their symptoms and mode of treatment ; an admirable 
collection of Formulae, and an account of the climates of the various parts of the world suitable for invalids. It 
also contains at the beginning of the work a tabular synopsis of subjects, which does double duty at once, a 
Nosology and an index. It will be found a most valuable companion to the judicious practitioner." — Lancet. 

Tanner's Memoranda of Poisons. 

From the Second London Edition. . . .... $0.50 



22 LINDSAY AND BLAKISTON'S PUBLICATIONS. 



Trousseau's Lectures on Clinical Medicine. 

Delivered at the Hotel Lieu, Paris, by A. Trousseau, Professor of Clini- 
cal Medicine in the Faculty of Medicine, Paris. Translated and edited, 
with Notes and Appendices, by P. Victoee Bazike, M.D., Assistant 
Physician to the National Hospital for the Paralyzed and Epileptic, &c. 
Parts 1, 2, and 3. Price of each Part. . . . . $2.00 

" This book furnishes us with an example of the best kind of clinical teaching, and we are much indebted 
to the translator for supplying the Profession with these admirable Lectures. It is a book which deserves to 
be popularized. We scarcely know of any work better fitted for presentation to a young man when entering 
upon the practical work of his life. The delineation of the recorded cases is graphic, and their narration de- 
void of that prolixity which, desirable as it is for purposes of extended analysis, is highly undesirable when 
the object is to point to a practical lesson." — London Medical Times and Gazette. 



Tyler Smith's Obstetrics, 



A Course of Lectures. By William Tyler Smith, M.D., Physician, Ac- 
coucheur, and Lecturer on Midwifery, and the Diseases of Females, in St 
Mary's Hospital, Medical School, &c, &c. With Numerous Illustrations. 
Edited by A. K. Gardner, M.D., Fellow of the New York Academy of 
Medicine, &c, &c. Octavo. $5.00 

These Lectures were first published in the columns of the London Lancet, and after 
being carefully revised by the author, and with many additions, was republished in 
book-form as one of ChurchilVs celebrated Manuals for Students. The high character and 
reputation of the work caused its publication in this country, where it has been received 
with much favor, and been adopted as a text in many of our medical schools and colleges. 

Thompson's Clinical Lectures on Pulmonary 
Consumption. 

By Theophilus Thompson, M.D., F.R.S., Fellow of the Royal College 
of Physicians, London, Sec, &c. With Illustrations. Octavo. $1.25. 

"Here will be found a clear exposition of the symptoms and their complications, — the details whereon to 
establish an unexceptionable diagnosis, from which naturally flows the prognosis and sound data for the 
treatment of the many complications which, as a whole, constitute Phthisis. We cannot notice these 
Lectures at the length commensurate with their great importance and high value. They form one of the most 
practical and useful works on the subject now before the Profession." — Lancet. 

Tilt's Elements of Health, and Principles of 
Female Hygiene. 

By F. J. Tilt, M.D., Senior Physician to the Lying-in Charity, Author 
of Works on the Diseases of Menstruation, Uterine Therapeutics, &c, 
&c. 12mo $1.50 

"Dr. Tilt divides life into the septennial epochs so long adopted by philosophers and medical men, discuss- 
ing, under the different ages, the physical and moral relations, diseases, &c, peculiar to each. The chapter 
devoted to the age from fourteen to twenty-one years contains much valuable advice respecting the menstrual 
function during that period. Tables showing the value of life at each of the different periods of life, are 
appended in their proper places; and the work also contains other statistics of value and interest. The 
whole work has been prepared with great care, and contains a large amount of valuable information, which 
professional men may consult with profit." — iV". F. Medical Times. 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 23 

Taylor's Theory and Practice of the Move- 
ment-Cure. 

i 

Or, the Treatment of Lateral Curvature of the Spine, Paralysis, Indigestion, 
Constipation, Consumption, Angular Curvatures, and other Deformities, 
Diseases Incident to Women, Derangements of the Nervous System, and 
other Chronic Affections, by the Swedish System of Localized Movements. 
By Charles Taylor, M.D. With Illustrations. 12mo. . $1.50 

The work of Dr. Taylor is a systematic treatise, containing the principles on which 
this treatment is based, and full and explicit directions in their application to indi- 
vidual diseases. The author discusses the nutritive processes, muscular contraction, 
and the physiology of general exercise, the subjects of the first three chapters, in a 
most satisfactory manner. The work is purely of a scientific character, and commends 
itself as such to the attention of all physicians. 

Virchow's Cellular Pathology. 

As based upon Physiological and Pathological History. Translated from 
the Second Edition of the Original By Frank Chance, B.A., M.A., 
Cantab Licentiate of the Royal College of Physicians, &c, &c. With 
Notes and Numerous Emendations, principally from MSS. Notes of the 
Author, and Illustrated by 144 Engravings. Octavo. . . $5.00 

Prof. Virchow and his writings are well known wherever the science of medicine is 
studied. This work has been selected by the Medical Bureau of the United States for 
general distribution in the hospitals and medical stations of the army ; recording, as 
it does, the researches in this branch of science down to the present time. 

The importance of the subject, the new ideas advanced, and the established repu- 
tation of the author, induced the publication of this book, and has made it a standard 
work throughout Europe and in this country. 

Virchow on Morbid Tumors. 

IN PREPARATION. 



Walker on Intermarriage. 



Or, the Mode in which, and the Causes why, Beauty, Health, and Intellect 
result from certain Unions, and Deformity, Disease, and Insanity from 
others. With Illustrations. By Alexander Walker, Author of 
"Woman," "Beauty," &c.,&c. 12mo. . . . . $1.50 

" The author is evidently a careful observer, and a proper thinker, and has presented us with a vast amount 
of information, derived both from man and the inferior animals. He has aimed to be useful, by pointing out 
how bodily deformities and mental infirmities may be forestalled; and how marriages among blood relations 
tend to the degeneracy of the offspring. He also shows how, by carefully assorted marriages, the means of 
improving general organization and beauty of countenance, as well as mental and physical vigor, are, in a 
great degree, under the control of man. Although not strictly a medical work, we cannot refrain from com* 
mending it to the perusal of the Profession, aa it contains much that ia valuable in a hygienic point of view." — 
Medical Examiner. 



24 



Wythes' Physician's Pocket, Dose, and Symp- 
tom Book. 

Containing the Doses and Uses of all the Pri?ieipal Articles of the Materia 
Medica, and Original Preparations; A Table of Weights and Mea- 
sures, Rules to Proportion the Doses of Medicines, Common Abbre- 
viations used in Writing Prescriptions, Table of Poisons and Antidotes, 
Classification of the Materia Medica, Dietetic Preparations, Table of 
Symptomatology, Outlines of General Pathology and Therapeutics, &c. 
By Joseph H. Wythes, A.M., M.D., &c. The Seventh Revised Edition. 

Price, in cloth, . $1.00 

" leather, tucks, with pockets, . . . . . 1.25 

This little manual has been received with much favor, and a large number of copies 
sold. It was compiled for the assistance of students, and to furnish a vade mecum for 
the general practitioner, which would save the trouble of reference to larger and more 
elaborate works. The present edition has undergone a careful revision. The thera- 
peutical arrangement of the Materia Medica has been added to it, together with such 
other improvements as it was thought might prove of value to the work. 



Waring's Manual of Practical Therapeutics. 

Considered chiefly with reference to Articles of the Materia Medica. By 
Edward John Waring, F.K.C.S., F.L.S., &c, &c. From the Second 
London Edition. Royal Octavo. 

Price, in cloth, . . ... . . . $6.00 

" in leather, . 7.00 

There are many features in Dr. Waring's Therapeutics which render it especially 
valuable to the Practitioner and Student of Medicine, much important and reliable in- 
formation being found in it not contained in similar works ; it also differs from them 
in its completeness, the convenience of its arrangement, and the greater prominence 
given to the medicinal application of the various articles of the Materia Medica in the 
treatment of morbid conditions of the Human Body, &c, &c. It is divided into two 
parts, the alphabetical arrangement being adopted throughout the volume. For the 
further convenience of the reader there is also added an Index op Diseases, with a 
list of the medicines applicable as remedies, and a full Index of the medicines and 
preparations noticed in the work. 

" Our admiration, not only for the immense industry of the author, but also of the great practical value of 
the volume, increases with every reading or consultation of it. We wish a copy could be put in the hands 
of every student or practitioner in the country. In our estimation it is the best book of the kind ever 
written." — N. Y. Medical Journal. 

" We have greatly enjoyed the examination of this volume. It is, indeed, one of the most practical works 
that has ever attracted our attention. Combining the merits of Wood, Beck, Stille, and the U. S. Dispen- 
satory, it forms a volume which no young physician can afford to be without." — Chicago Medical Journal. 

" Mr. Waring has produced a volume which entitles him to the thanks of students as well as of all who 
need a work on Therapeutics ; it implies very extensive reading and pains-taking industry in its preparation. 
We commend it to the attention of the Profession." — American Medical Journal. 

" This work is a monument of industry and perseverance. As a work of reference, it is invaluable both 
to the practitioner and student." — Canada Medical Journal. 



PUBLICATIONS. 25 



Walton's Operative Ophthalmic Surgery. 

By Haynes Walton, F.R.C.S., Surgeon to the Central London Ophthal- 
mic Hospital, &c. With 169 Illustrations. Edited by S. Littell, 
M.D., Surgeon to the Wills Hospital for the Diseases of the Eye, &c. 
Octavo $4.00 

"It is eminently a practical work, evincing in its author great research, a thorough knowledge of his sub- 
ject, and an accurate and most observing mind." — Dublin Quarterly Journal. 

Watson's Practice abridged. 

A Synopsis of the Lectures on the Principles and Practice of Physic. De- 
livered at King's College, London, by Thomas Watson, M.D., Fellow. 
of the Royal College of Physicians, &c, &c. From the last London 
Edition. With a concise but Complete Account of the Properties, Uses, 
Preparations, Doses, &c, of ail the Medicines mentioned in these Lectures, 
and other Valuable Additions, by J. J. Meylor, A.M., M.D., &c, &c. 
A neat Pocket Volume bound in cloth flexible. . . . $2.00 

The merits of this Abridgment and the advantages claimed for it are : 1, that it is of 
pocket-size; 2, that it contains every thing of importance to be found in the large 
work ; 3, that the lectures, being short, can be read in a few minutes ; 4, that the 
matter of each lecture is divided, according to the subject, into parts, by such side- 
heads as Symptoms, Treatment, Causes, Diagnosis, Prognosis, &c, thus rendering it easy 
to obtain at a glance any required information ; 5, that, being numbered as in the large 
work, the lectures can readily be compared with the original; 6, that, in addition to 
the various tables, and the List of Poisons, their Symptoms and Treatment, it contains 
a short account of the Uses, Preparations, Doses, &c. (taken from the United States 
Dispensatory) of the many medicines mentioned in the work. 

Zander on the Ophthalmoscope. 

Its Varieties and its Use. Translated from the German of Adolf Zander, 
by Robt. B. Carter, F.R.C.S., etc., etc. With Notes and Additions 
by the Translator. Containing three full-page Colored Illustrations, and 
Numerous other Illustrations engraved on wood. Royal Octavo. $4.00 

"Thirteen years have elapsed since the discovery of the Ophthalmoscope. An instrument that afforded 
methods of research so new and so extensive, rested for a while, of necessity, in the hands of a small number 
of observers, who by the possession of special knowledge and special opportunities were enabled thoroughly 
to test its usefulness, and rightly to appreciate its value. The knowledge laboriously obtained and perfected 
by a few, has now to be diffused through and utilized by the great bulk of the Profession. Specialists may 
yet effect improvements in matters of detail, and refinements in methods of observation, but the great prin- 
ciples on which these must depend are already ascertained and established. In this belief I have thought it 
desirable to prepare an English version of Dr. Zander's exhaustive and masterly treatise." — Translator's 
Preface. 



Skey on Hysteria. 



IN PREPARATION. 



Remote Causes of Disease in General Treatment of Disease, by Tonic 
Agency, Local or Surgical Forms of Hysteria, &c. Lectures delivered to 
the Students of Si. Bartholomew's Hospital. By F. C. Skey, F.R.S., 
Consulting Surgeon to St. Bartholomew's Hospital, &c, &c. 



26 LINDSAY AND BLAKISTOtf's PUBLICATIONS. 



Harris's Dictionary of Medical Terminology, 

Dental Surgery, and the Collateral Sciences. By Chapin A. 
Harris, M.D., D.D.S., Professor of the Principles of Dental Surgery in 

. the Baltimore College, Member of the American Medical Association, &c, 
&c. The Third Edition, carefully revised and enlarged, by Ferdi- 
nand J. S. Gorgas, M.D., D.D.S., Professor of Dental Surgery in the 
Baltimore College, &c, &c. Royal octavo. 

This Dictionary has been for a long time out of print ; a new edition has been much 
needed by the Profession, a constant and increasing demand existing for it. The* pres- 
ent edition has been thoroughly revised by Professor Gorgas, Dr. Harris's successor in 
' the Baltimore Dental College. Many additions and corrections have been made, and 
some iwo to three thousand new words added. The doses of the more prominent medici- 
nal agents have also been added, and in every way the book has been greatly im- 
proved, and its value enhanced. , 

Harris's Principles and Practice of Dental 

Surgery. 

The Ninth Edition, with 320 Illustrations. Royal octavo. 
Price, bound in cloth, bevelled boards, .... $6.00 
leather, . 7.00 

This edition of Dr. Harris's work has been subjected to a very thorough revision 
by competent professional gentlemen, and contains many and important additions, 
bringing the work fully up to the present state of dental science, and adding greatly 
to its value. The illustrations have also been much improved ; some have been replaced 
by new drawings, and many new ones have been added. The publishers therefore 
offer it with the confident assurance that it will now be found a thorough elementary 
treatise, a text-book for the student, and a useful companion and guide for the 
practitioner. 

Bond's Practical Treatise on Dental Medicine. 

Being a Compendium of Medical Science, as Connected with the Study of 
Dental Surgery. By Thomas E. Bond, M.D., Professor of Special 
Pathology and Therapeutics in the Baltimore College of Dental Surgery. 
The Third Edition. Octavo. $3.00 

"We have spoken, or intended to speak, heartily in praise of Dr. Bond's work. It has unmistakable evi- 
dence of thorough medical science in its subject-matter, and cf a capital authorship in its 6tyle and treat 
mont." — American Medical Journal. 

Robertson's Manual on Extracting Teeth. 

Founded on tlie Anatomy of the Parts involved in the Operation, the Kinds 
and Proper Construction of the Instruments to be Used, the Accidents 
lihely to occur from the Operation, and the Proper Remedies to be Used. 
By A. Kobertson, M.D., D.D.S., &c. 12mo. .. . . $1.50 

" This work is valuable not only to the dental student and practitioner, but also to the medical student an<5 
inrgeon." — Dental Cosmos. 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 27 



I 



Taft's Practical Treatise on Operative Den- 
tistry. 

A NEW EDITION, THOROUGHLY REVISED. 

By Jonathan Taft, D.D.S., Professor of Operative Dentistry in the Ohio 
College of Dental Surgery, &c. The Second Edition, thoroughly Revised, 
with additions, and fully brought up to the present state of the Science. 
Containing over 100 Illustrations. Octavo. 

"An examination of Mr. Taft's treatise enables us to speak most favorably of it. It is very thorough and 
very clear, showing that the author is practically familiar with the art which he teaches. The engravings- 
<>.re abundant and excellent, and, in fact, the whole mechanical execution of the volume is admirable, and 
r eflect8 much credit on the publishers." — Boston Medical and Surgical Journal. 

Fox on the Human Teeth. 

Their Natural History and Structure, the Treatment of the Diseases to 
which they are Subject, the Mode of Inserting Artificial Teeth, &c. Edited 
by Chapin A. Harris, M.D., D.D.S., &c. With 250 Illustrations. 
Octavo $4.00 

Richardson's Practical Treatise on Mechani- 
cal Dentistry. 

By Joseph Richardson, D.D.S., Professor of Mechanical Dentistry in 
the Ohio College of Dental Surgery, &c. With over 100 beautifully exe- 
cuted Illustrations. Octavo. $3.50 

Handy's Text-Book of Anatomy, 

And Guide to Dissections. For the Use of Students of Medicine and 
Dental Surgery. By Washington R. Handy, M.D., late Professor of 
Anatomy and Physiology in the Baltimore College of Dental Surgery. 
With 312 Illustrations. Octavo $4.00 

"We heartily commend it to both the medical and dental profession, as a thorough, faithful, and physi- 
ological treatise on Anatomy." — American Journal of Dental Science. 

Piggot's Dental Chemistry and Metallurgy. 

Containing Physiological Chemistry, as Applied to Dentistry, &c. By A. 
Snowden Piggot, M.D., Professor of Practical and Analytical Chem- 
istry, &c. In one Volume, octavo. $3.50 

" We think the work is one which should be in the hands of every dentist. Much labor and research has 
been spent on it, and an immense amount of useful information combined and given in a very desirable form 
to the Profession." — Dental Register. 

Tomes' System of Dental Surgery. 

By John Tomes, F.R.S., Dentist to the Dental Hospital of London, Author 
of " Tomes' Dental Physiology^ &c, &c. With 208 beautifully executed 
Illustrations. Octavo. $4.50 

" This is an ably written and valuable work, containing much matter that cannot be found elsewhere, and 
calculated to enhance the reputition of tbf> author a? an original and careful observer." — Dental Cosmos. 



28 LINDSAY AND BLAKISTON'S PUBLICATIONS. 

Cooley's Toilet and Cosmetic Arts. 

The Toilet and Cosmetic Arts, in Ancient and Modern Times. With a 
Review of the Different Theories of Beauty and copious allied Informa- 
tion, Social, Hygienic, and Medical, including Instructions and Cautions 
respecting the Selection and Use of Perfumes, Cosmetics, and other Toilet 
Articles; and a Comprehensive Collection of Formulas, and Directions 
for their Preparation. By Arnold J. Cooley, Author of " Cyclopaedia 
of Receipts : Processes, Data, and Collateral Information, &c, in the Arts 
and Manufactures." With Index to about 5000 Matters of Interest, Use 
or Caution. Demi-Octavo $5.00 

Ott on the Manufacture of Soaps and Candles. 

Including the Most Recent Discoveries, embracing all hinds of Ordinary 

Hard, Soft, and Toilet Soaps, especially those made by the Cold Process ; 

and the Modes of Detecting Frauds in the Manufacturing and the Making 

of Tallow and Composite Candles. By Adolph Ott, Practical and 

Analytical Chemist. 12mo. With Illustrations. (Just ready.) $2.50 

The author, in preparing this volume, has been careful to give a clear and concise 

account of the art of soap and candle making, as now practised, so as to make the work 

as practical in its character as possible. Appropriate illustrations have been added, 

and critical explanations of the various manipulations and mechanical arrangements, 

by which they are effected. Much new matter has also been incorporated in the book, 

never before published. 

Piesse's Whole Art of Perfumery. 

A NEW EEVISED AND ENLARGED EDITION. 

And the Methods of Obtaining the Odors of Plants ; with Instructions for 
. the Manufacture of Perfumes for the Handkerchief, Scented Powders, 
Odorous Vinegars, Dentifrices, Pomatums, Cosmetics, Perfumed Soaps, 
&c; to which is added an Appendix, on Preparing Artificial Fruit 
Essences, &c. By G. W. Septimus Piesse, Analytical Chemist. A new 
American from the Third London Edition. 12mo. With Numerous 

Rlustrations. ' . . . . $3.00 

Dr. Piesse's volume covers the entire ground of the subject upon which it treats. 
It is full of Useful and Curious Information, including also many Valuable Formulae; 
and will be found of equal importance and interest to the practical man as to the gen- 
eral reader. 

Overman's Practical Mineralogy, Assaying 
and Mining. 

With a Description of the Useful Minerals, and Instructions for Assaying, 
according to the simplest Methods. By Frederick Overman, Mining 

Engineer, &c. 12mo. . . .'.'._ $1.25 

The object of this volume is to place before the public the characteristics and use? 
of minerals, in a popular style, avoiding, as far as possible, the use of scientific and 
technical terms. The subject is divided into three parts: — Mineralogy, or a Descrip- 
tion of the Appearance of Minerals, with the localities in which they may or have been 
found ; Assaying, or an Investigation of the value of Minerals, by means which are 
within the reach of every one ; and Practical Mining in its simplest form. 

Piggott on Copper Mining and Copper Ore. 

Containing a full Description of some of the Principal Copper Mines of the 
United States, the Art of Mining, the Mode of Preparing the Ore for 
Market, &c., &c. By A. Snowden Piggott, M.D., Practical Chemist. 
12mo. . . / . . . . . . . . $1.50 



I 



LINDSAY AND BLAKISTON ; S PUBLICATIONS 29 

Morfit's Chemical and Pharmaceutical Man- 
ipulations. 

A Manual of the Chemical and Chemicv-Mechanical Operations of the 
laboratory. By Campbell Morfit, Professor of Analytic and Applied 
Chemistry in the University of Maryland, assisted by Clarence Morfit, 
Assistant Melter and Refiner in the United States Assay Office. The 
Second Edition, Revised and Greatly Enlarged, with over 500 Illustra- 
tions. Octavo $5.00 

"The arrangement of the whole is such, that every student will be able to go through the work without a 
(juide to lead him, provided the necessary apparatus are at hi3 command. But even without them, a careful 
study of the book will give tbe attentive student a very useful insight in all the manipulations of the pharma- 
ceutical chemist, and thousands, no doubt, who are prevented from attending the schools of pharmacy and 
chemistry, will gladly avail themselves of the only means left them for self-improvement. The amount of 
perseverance and industry displayed in the getting up of this work is truly astonishing, the clearness of ex- 
pression in every sentence, and the accurateness of the 500 illustrations, are above praise. 'Morfit's Manipula- 
tions' ranges in utility immediately after the United States Dispensatory." — Chemical Gazette. 

Wetherill on the Manufacture of Vinegar. 

Theoretical and Practical, ivith Especial Reference to the Quick Process. 
With Rides for Testing its Purity, &c, &c, and Illustrations. By 
Charles Wetherill, M'.D. 12mo. ... . . . $1.50 

The purity of vinegar is of more importance to the public generally even than alco- 
holic liquors, to the adulteration of which so much attention has recently been given, 
entering as it does more or less, in some shape or other, into the consumption of every 
member of each and every family, and being more insidious in its effects. Viewing it 
in this light, the author, a practical chemist, has furnished simple processes by which 
its purity can be readily tested, by either the dealer in the article, or the consumer. 

Campbell's Manual of Scientific and Practical 
Agriculture. 

A Systematic Arrangement of all Scientific Knowledge bearing in any man- 
ner on the great ivork of Farming. For the use of Schools and Farmers. 
By Prof. J. L. Campbell, of Washington College, Va. 12mo. With 

Illustrations. . $1.50 

This volume has been prepared to supply those already engaged in the culture of the 
soil with a guide, the study or perusal of which will enable them to improve upon the 
old system, or rather want of system, which has worn out so much of our best land, 
and has rendered the pursuit, in so many instances, unprofitable ; and also to meet the 
demands of teachers for a text-book of the right kind, which will give the student such 
information as will fit him for the intelligent pursuit of agriculture as a .business. 

Darlington's Flora Cestrica; 

Or, Herborizing Companion. Containing all the Plants of the Middle 
States, their Linncean Arrangement, a Glossary of Botanical Terms, a 
complete Index, etc. By William Darlington, M.D. The Third 
Edition, enlarged. 12mo $2.25 

Miller on Alcohol, and Lizars on Tobacco. 

Alcohol: Its Place and Power. By James Miller, F.K.S.E., Professor 
of Surgery in the University of Edinburgh; President of the Medico- 
Chirurgical Society ; Author of Miller's Principles and Practice of 
Surgery, etc., etc. The Use and Abuse of Tobacco. By John Lizars, 
late Professor of Surgery to the Royal College of Surgeons, etc., etc. The 

Two Essays in One Volume. 12mo $1.00 

The first of these treatises was prepared by Prof. Miller at the request of the Scot- 
tish Temperance League, who were anxious to have a work of high authority, present- 
ing the medical view of the Temperance question. It has passed through a great 
number of editions in Scotland, and has had a large sale in this country. The second 
was^ prepared by Prof. Lizars to show the pernicious consequences of excessive or 
habitual smoking. If purchased in quantities, either together or separately, by Tem- 
perance or other societies, they will be furnished at a reduced price 



LINDSAY & BLAKISTON'S PUBLICATIONS. 



CHAMBEES' LECTURES. 

OPINIONS O F T H E PRESS. 

" The medical profession in this country are under obligations to the American pub- 
fishers for this reprint of Dr. Chambers' Lectures — a work whose time is forever, every- 
where in its place, admirable in tone, full of valuable instructions and practical teachings, 
and written in clear, compact, and often epigrammatic English. We can offer but a brief 
notice of this intrinsically good book, which is certain of finding a wide circle of readers, 
and we should hope a place in every medical library/' — New York Medical Journal. 

" We are pleased to see this work rendered accessible to the profession in this country. 
it is well calculated to awaken thought and inquiry in the right direction." — American 
Medical Journal. 

" We have deferred noticing this elegant volume until we could find time to give it 
more than a cursory perusal, and have found ourselves fully compensated for the careful 
reading which the delay has afforded us. Few medical books have given us so much 
pleasure, few are invested with such a fascinating charm of manner, few are so full of 
practical suggestions of permanent value to the practitioner. We cannot too highly 
f-eeomniend it to the most diligent study of all progressive members of the profession/' 
Boston Med. and Surg. Journal. 

" The work is of the highest merit, written in a clear, masterly style, and devoid of 
technicalities. It is simply what it professes to be, Lectures Clinical, delivered from 
cases observed at the bedside ; therefore more valuable as enunciating the views and 
experiences of a practical mind aided by actual observation. They are of deep interest 
and replete with facts having a practical bearing, and will well repay perusal. . . . We 
can recommend Dr. Chambers' book freely and with confidence as the work of a great 
mind, practical in its bearing, and simple to the understanding of all." — Canada Med. 
Journal. ■ 

" We are heartily glad to see such books in the hands of our profession. They tend to 
cultivate its higher philosophy. There is nothing we so much require as to be constantly 
able to say exactly why we pursue a particular therapeutic course in any given disease'; 
and the careful reader of this book we are very sure will lay it down with the largely 
increased ability to render a reason for the faith that is in him." — Lancet and Observer. 

" Dr. Chambers has long occupied a distinguished professional position as a writer and 
lecturer. He is preeminent for his scientific investigations in physiology and pathology, 
and for his philosophical deductions. His ideas are never commonplace, and whether 
they are well founded or not, they are always interesting as the products of a mind that 
is in profound earnest in dealing with the mysteries of disease and its rational methods 
of treatment." — American Druggists' Circular. 

" As specimens of the colloquial style it will be difficult to find their equal in medical 
literature. But this is by no means their only merit. Their practical teachings claim no 
less our attention. Both student and practitioner will do well to give these lectures a 
eareful study, for therein they will find accurate guides to diagnosis, and hints with 
regard to the management and treatment of disease, which, without always subscribing 
to*the author's views of their action, they will gladly adopt." — Med. and Surg. Itevorter. 

" It is a very able and scholarly production, which may be studied with both pleasure 
and profit, the subject-matter being generally treated in such a lucid, logical, original, 
and sprightly manner as to enchain the attention while appealing to the judgment. The 
high scientific character and practical value of this meritorious publication may be 
directly estimated by the author's instructive observations ' on the formation of mucus 
und pus/ " — Dental Cosmos. 

" The work is a scholarly production, well and clearly written, and we recommend it 
with pleasure to the profession." — American Literary Gazette, 



LINDSAY k ULAKISTON'S PUBLICATIONS. 



CAZEATJX'S OBSTETEIOS. 

The Fourth American Edition of M. Cazeaux's work has been translated and 
reprinted from the Sixth French edition, which was completely re- written and 
thoroughly revised by the author. The pupil of Moreau, long the clinical chief 
to Professor Dubois, and for sixteen years adjunct Professor of Midwifery in 
the schools of Paris, he stands before us a teacher qualified by ability, experi- 
ence, and information, to impart instruction to many, and command the respect 
of all. A very extensive acquaintance with the views and practice of those mas- 
ters in his art who preceded him, and his position in one of the largest lying-in 
hospitals in the world, enabled M. Cazeaux to test by rigid experiment the valui* 
of the doctrines promulgated by former authors. The publishers append a few 
of the many favorable opinions they have received of the work : 

" The call for repeated editions of this elaborate and most excellent work, gives grati- 
fying evidence of the advanced state of obstetrical science in this country. This treatise 
has long been popular in France as the principal text-book. Every question in theoreti- 
cal and practical midwifery is fully discussed, and the rules established for the guidance 
of the practitioner are based upon the most enlightened views of physiology and pathology. 
The work cannot be too strongly recommended to the American student and practitioner." 
New York Medical Times. 

" It is one of the most complete treatises on midwifery in the English language. It 
embraces a full and complete discussion of every subject relating to obstetrics, entering 
largely into the theories and principles of the science, and giving in detail the rules of 
practice." — New York Journal of Medicine. 

"This magnificent work is too well known to the majority of our readers to require 
extended comment. It is a book of classical standing and authority in France, and it 
must rank among the first in any language." — Chicago Medical Journal. 

" Cazeaux especially is well deserving an English dress as emanating from the distin- 
guished obstetrical school of which Naglee was the founder, and Dubois one of the most 
eminent teachers. The translator deserves credit for performing his task so well." 
Trans. Am. Med. Association. 

"We cannot but admire the completeness and comprehensiveness of the work, and we 
have no hesitation in recommending it as one of the best guides that we have in our lan- 
guage." — Lancet and Observer. 

" Brought down to the latest period, whatever is new, useful, or suggestive, has been 
faithfully incorporated with the text." — Boston Med. and Surg. Journal. 

" We cannot do less than commend this book to the careful perusal of the student and 
practitioner, assuring both that they will be amply rewarded for a careful study of the 
work." — New Orleans Med. and Surg. Journal. 

"Of all the elementary works on obstetrics I have read for a long time, ' Cazeaux' is 
the best. On the subject of embryology and the mechanism of labor, no other will com- 
pare with it. I have looked over the translation by Dr. Bullock, and find it both elegant 
and faithful." — B. Fordyce Barker, M.D., Professor of Midwifery N. Y. Med. College. 

" I have always highly regarded the work, and taken occasion to recommend it to my 
class. It contains more useful and practical information on the subject than any work 
I have ever read, and presents it in the right manner." — D. V. P. Quackenbush, M.D,. 
Professor of Obstetrics Albany Medical College. 



Lindsay & Blakiston's 
PHYSICIAN'S YISITING LIST. 

PUBLISHED ANNUALLY. 

NOW HEADY FOR 1868. 



This is the Original " Visiting List," the first published in the United States. 

It forms an invaluable Pocket Companion for every Physician, compact, easily car- 
ried in the pocket, methodical in its arrangement, and so useful that the Physician 
once using it will never afterwards be without it. "It will cost the Physician a dol- 
lar or two ; it will save him as many hundreds." 



COB"TE]NrTS 

1. Table of Signs, or Guide for Registering Visits, En- 

gagements, &c. 

2. An Almanac for 1868. 

3. Marshall Hall"s Ready Method in Asphyxia. 

4. Poisons and their Antidotes. 

5. Table for Calculating the Period of Utero-Gestation. 

6. The Visiting List arranged for 25, 60, or 100 

Patients. 



7. Memoranda pages for every month in the year. 

8. Pages for Addresses of Patients, &c. 

9. " Bills and Accounts asked for and de- 
livered. 

10. " Obstetric Engagements. 

11. " Vaccination " 

12. " Recording Obstetric Cases, Deaths, and 
for General Memoranda. 



SIZES -A-IETD ZPDEfclCiE. 

For 25 patients weekly, bound in cloth, $0 75 

25 " " " leather, with tucks and pocket, . . 1 25 

50 " " « cloth, . . . . . . .100 

50 " V " leather, with tucks and pocket, . . 1 50 

100 " " « " « ?< 2 50 



100 " " in 2vni« /Jan'y to June. ) bound in leather, with 

vtus. | July tQ Dec , rj | tucks and pQcketj 



3 00 



AN INTERLEAVED EDITION, 

for the use of Country Physicians and others who compound their own Prescriptions, 
or furnish Medicines to their patients. The additional pages can also be used for Spe- 
cial Memoranda, recording important cases, &c, &c. 

For 25 patients weekly, interleaved and bound in cloth, . . . . $1 00 

25 « " " " « tucks, with pocket, . 1 50 

50 " " m " » cloth, . . . . 1 50 

50 " " " " » tucks, with pocket, . 2 00 

This Visiting List has now been published for Seventeen Years, and has met with 
such uniform and hearty approval from the Profession, that the demand for it has 
steadily increased from year to year, so much so that the Publishers have found it 
necessary to prepare it for circulation several months previous to the first of the year. 
Physicians who are in the habit of using it, or intend doing so, should give their 
orders in advance for it, that no disappointment or inconvenience may result from 
being without it. It can be procured from the principal booksellers in any of the large 
cities of the United States and Canada, or copies will be forwarded by meal, free of 
postage, by the Publishers, upon receipt by them of the retail price as annexed. 

In ordering the work from other booksellers, order 

Ztindsay & Htlakiston's- ^Physician's Visiting Zist. 

And in all cases, whether ordering from the Publishers or otherwise, specify the 
size, style, &c, wanted. 

LINDSAY & BLAKISTON, Publishers, 

25 South Sixth St., Philadelphia* 



